Monday, May 30, 2011

Osteoid Osteoma-Ulna

15 years old girl comes with pain along the extensor carpi ulnaris tendon ( ECU) with clinical diagnosis of extensor carpi ulnaris groove syndrome.


Case Submitted By-
  1. DR.M.G.K.MURTHY, SR.CONSULTANT RADIOLOGIST
  2. MR.ABDUL HAMID

Teaching Points
- ECU arises by two tendons one from lateral epicondyle and the other the mid 1/3rd of the posterior ulna and its inserts into the posterior base of the 5th metacarpal. ECU passes the groove on the medial side of the distal ulna and its covered by the annular ligament.

 
- CT shows small well defined, regular, subperiosteal, septated mixed density lesion with a hyperdense speck as the nidus with no soft tissue abnormality or joint abnormality with no significant periosteal response suggesting osteoid osteoma.

- Osteoid osteoma, and tenosynovitis along the ECU are difficult to differentiate on clinical grounds.

 

Glenoid Fracture- Teaching Points

Questions between Reporting doctor and Professor. Submitted by Dr MGK Murthy


What is this?
Answer- it is a fracture

Where?
Involves infraglenoid tubercle and axillary(lateral border)of scapula

What is the importance?
Triceps get origin from infraglenoid tubercle and teres muscles get attachment from the border

How is the joint ?
Gleno-humeral joint is maintained

What causes it?
Scapular neck fractures most frequently result from an anterior or posterior force applied to the shoulder. Glenoid rim fractures most often result from force transmitted along the humerus after a fall onto a flexed elbow. Stellate glenoid fractures usually follow a direct blow to the lateral shoulder

Types ?
Classification of glenoid cavity fractures: IA - Anterior rim fracture; IB - Posterior rim fracture; II - Fracture line through the glenoid fossa exiting at the lateral border of the scapula; III - Fracture line through the glenoid fossa exiting at the superior border of the scapula; IV - Fracture line through the glenoid fossa exiting at the medial border of the scapula; VA - Combination of types II and IV; VB - Combination of types III and IV; VC - Combination of types II, III, and IV; VI - Comminuted fracture

Which is this ?
It is possible type II

What next
MDCT with reconstructions

Wednesday, May 25, 2011

Leber's Optic Atrophy-DTI

18 yr old student has developed sudden visual loss in one eye with history of maternal uncles having been blind in youth. Clinical exam and eye evaluation suggested hereditary optic atrophy . MRI showed symmetrical thinning of the optic nerves in introorbital regions consistent with lebers variety of hereditary optic atrophy. Case by Dr MGK Murthy and Mr Hari Om.






Teaching points

• It is mitochondrial neurodegenerative disease acquired through the mutated genes. Females pass it on and affected males do not
• It is bilateral with simultaneous(25%) or sequential (75%)involvement of both eyes
• Starts in young age with males(24 years mean) affected earlier than females(31years)
• Sometimes coexists with Multiple sclerosis when it is called Hardings syndrome
• LHON plus is referred to the Lebers Atophy with other diseases like movement disorders and cardiac arrhythmias
• Pathology is limited to retinal ganglion cell layer with reduced glutamate transportation

Optic nerve has various components and MRI can delineate them all
  1. Intraocular component 1mm
  2. Intraorbital 25 mm
  3. Intracanalicular 5mm
  4.  Intracranial 10 mm
Visual pathway
Optic nerves- optic chiasma- optic tracts- lateral geniculate bodies in the pulvinar –superior colliculi of brainstem-visual cortex of occipital lobes . This could be effectively depicted on Diffusion Tractography

Tuesday, May 24, 2011

Doctors Need to be on Social Media -Are Radiologists Listening?

Noted Medblogger KevinMD has these comments on his blog today- “Doctors who are not active online risk being marginalized. Facebook and Twitter users, half of whom are under of age of 34, rely on the web for most of their information. As this demographic ages, it’s conceivable that they will consult social media first to answer their health questions.

These statements pobably should serve as an eye opener to many doctors especially in India who still dont realize the importance of internet in this web 2.0 era.  You cant just ignore the facebook generation.

Monday, May 23, 2011

Patellar Sleeve Avulsion Fracture-Plain Film


Young male with sporting macro-trauma history with pain and tenderness of lower patellar region with soft tissue swelling of 2 months duration. X ray shows  lower polar irregularity , heterogenous opacities and soft issue swelling – compatible with patellar sleeve avulsion fracture of children. Case submitted by Dr MGK Murthy




Teaching points

1.    Patella is sesamoid bone  in the tendon of quadriceps muscle with dense cancellous bone with thin compact lamina.
2.    Ossifies from single ossification center(sometimes two) appearing from 2-6 yrs age and completes by puberty.
3.    Affects chondro-oseous junction  with an extensive sleeve of cartilage pulled of the main body ,with patellar tendon disruption


Avulsion Injury-Plain Film



An adolescent with athletic injury shows bony avulsion of anterior superior iliac spine –avulsion fracture. Most benign of bony injuries generally. Heals with conservative management in 4-6 weeks. Case submitted by Dr MGK Murthy




Teaching points
  • Avulsion fractures are common in appendicular skeleton with most occurring in the growing age due to athletic activity, and immature bony skeleton.
  • Anterior superior iliac spine- gives origin to Sartorius and tensor fascia lata.
  • Anterior inferior  iliac spine (just below the Superior spine)has two parts, upper gives origin to – origin to straight head of rectus femoris  and lower part give attachment to iliofemoral ligament and reaches to form the acetabular margin. 
  • Ischial tuberosity- gives origin to hamstrings(Biceps femoris, semitendinosis and semimembranosis)
  •   Greater tuberosity-attachement to hip rotators(piriformis, gemellus superior and inferior, obturator internus and externus , quadrates femoris)
  •   Lesser tuberosity-to iliopsoas


      

    Sunday, May 22, 2011

    Errors in Radiology



    How often we have seen that showing a same chest xray or mammogram to two different radiologists will get us different results. Do they get counted as errors? Often somebody labels the bronchovascular markings as prominent while other will call it normal. Even PNS xrays sometimes, one radiologist will call sinus hazy and other will call it clear. Looking back at the medical college days where each report was double or triple read, junior resident-then registrar then-faculty. Probably makes some sense to have some kind of standard double reads in the process to increase accuracy and to cut down on ambiguity.  It is also often postulated that computer may play a significant role in future in pattern recognition and radiologists will superread the studies, this will increase the efficiency and reduce errors of missing a significant pathology.

    What do you think of this? How you ever tried reporting same xray on two different days and found yourself writing different reports? Comments and suggestions are welcome.

    Thursday, May 19, 2011

    Trauma Metacarpophalangeal joint


    Adolescent male with sporting injury to thumb clinically

    Xray shows widening of the ulnar side of thumb MCP joint with no bony injury  and sof tissue haziness in periarticular location-possibly sprain in the  form of collateral ligament injury, sesamoids though atypical in position are not injured. MRI would  help delineate the ligamentous injury and occult bone marrow oedema. Case submitted by Dr MGK Murthy.

    Teaching points--
    Hinged(condyloid joint) with shallow proximal phalanx base articulation with spherical(thumb rather quadrilateral)metacarpal head
    Thumb MCP gets more often injured than relatively stable finger MCP
    Factors for stability include soft issue contractility including volar plate, true and accessory collateral ligaments , sagittal band, dorsal capsule, extrinsic and intrinsic tendons
    Range permitted usually is 30 deg hypertext, 120 deg flexion, 30 to 40deg mediolateral laxity and small rotation
    Volar plate is most susceptible for injury
    Usually trauma leads to sprains in the form of  collateral ligament  injury(25 to 40%)
    When dislocated, dorsal more common than palmar
    Dorsal is described simple if no soft tissue interposed and complex other wise
    Two level dislocations are when concomitant Bennett or interphalangeal joint is involved as well
    Xray is adequate particularly if additional views (to AP/Lat and Obique ) are added
    (a) Brewertons view- place proximal phalanx touching on the cassette after flexing MCP joint to 65 degrees and angulate the beam 15 degress from ulnar to radial side
    (b) True lateral of the digit/thumb concerned rather than hand
    1. Hands have 5 sesamoids (nodule of calcium within tendons or joint capsule) , with 2 at MCP joint, and 1 at interphalangeal joint of thumb, with  rest at MCP joints of index and small fingers

    2. Position of the sesamoids while could help, decide the articulation postion, they usually do not dislocate , however could be fractured, infected, inflamed, or turn neoplastic 

    Tuesday, May 17, 2011

    The Rizalistas of Rongot

    Author's note: This article originally appeared in The Philippine Online Chronicles, now the world's leading portal of knowledge about the Philippines and its people. Please visit our website here.

    The town of Calamba, in the province of Laguna--by virtue of having been the birthplace of Dr. Jose Rizal--has become a pilgrimage site not only for those wanting to pay homage to the Philippine National Hero, but more importantly for the Rizalistas who worship Rizal as God.

    Calamba is said to be the new "promised land" where God Rizal shall establish His kingdom after the old world has been destroyed in the apocalypse. At the very center of this kingdom will be the barrio of Rongot, presently Calamba's poorest community, but which will eventually be the New Jerusalem.

    This is the belief of the religious sect called Iglesia Sagrada Familia, a small but intensely dedicated group of Rizalistas found in Sitio Rongot, Calamba, Laguna. Led by a vibrant old lady named Gloria Bibat, 84, the Iglesia Sagrada Familia worships Dr. Jose Rizal as God. They call Rizal not as Dr. Rizal but as Amang Rizal (Father Rizal) or simply Amang Doctor (Father Doctor).

    I first met Nanay Gloria during the street parade of Rizalistas in Calamba on the occasion of Rizal's 149th birth anniversary last June 19, 2010. In her characteristic vim, Nanay Gloria was leading the procession amidst the hot mid-day sun along the streets of Calamba, the birthplace of the National Hero. She was holding aloft the Philippine flag and a banner imprinted with a picture of Rizal.

    After the parade, Nanay Gloria and her members sought refuge in the shade in front of Rizal's house, and ate their packed lunch. Nanay Gloria invited me to partake of their food which consisted mainly of rice, small dried sardines, and steamed vegetables. I declined their kind offer, but Nanay Gloria insisted, giving me a plate and a plastic spoon. "Kumain ka na anak," she said to me. While we were eating, she told me that I should visit the Holy Land someday. I found that the Holy Land she was talking about was actually the barrio where her church is located, Sitio Rongot, only five kilometers from Calamba's town proper.

    Secluded Sitio Rongot

    Sitio Rongot is located in the remotest portion of Calamba, and is hardly accessible by vehicles. Isolated from the rest of Calamba by a narrow five-kilometer dirt road, only one vehicle can pass through it at a given time. In the unfortunate case when two vehicles meet head-on, one has to give way, retreat, and find the part of the road wide enough for both to pass through. The road is rough and dusty during the dry season, and wet and muddy during the rainy season. It is therefore understandable that even the local tricycles have to charge P150 to anyone coming in or out of the barrio. Most of the Rongot residents are poor, so they prefer to walk rather than pay the exorbitant amount.

    The sitio, however, receives a few visitors every Sunday, mostly students from the Manila universities who are taking Rizal courses and are assigned to interview the Rizalistas. Aside from these students, very few tourists ever care to visit Rongot. In fact, there is really nothing much to see, save for the mystical Mount Makiling beyond the horizon, and the Laguna de Bay just at the edge of the barrio.

    Despite its promise of becoming a Holy Land someday, Rongot is at present an impoverished community. Most residents eke out a living by fishing, farming, raising ducks, or gatheringkangkong and talbos ng kamote from the marshes. In fact, Calamba townspeople sometimes call the Rongot people as "magka-kangkong" (people who gather kangkong)

    Like most rural towns in the Philippines, Rongot exhibits an ambience of quietness and stillness. The only sounds one can hear are the soft winds from Laguna de Bay, the muffled noise of little children playing near the lake, and from time to time, the occasional barking of neighborhood dogs from a distance.

    People go about their daily lives in a relaxed and unhurried manner: the men gathering vegetables from the marshes, women tending to their little babies, young lads playing board games on benches, and old folks relaxing under the shade of trees -- whiling time away. Around the village one can see numerous small wooden houses, old empty boats docked along the bay and, on the bay itself, green water lilies that grow abundantly.

    The Church of the Iglesia Sagrada Familia

    At the edge of the barrio, very close to the bay, lies the modest temple of the Iglesia Sagrada Familia — a small rectangular white edifice built on multiple concrete stilts, two of which go down into the lake so that part of the church "stands" on water. The Iglesia meets here every Sunday at seven in the morning. The church members are mostly women in their octogenarian years, led by Nanay Gloria Bibat. There are some young male members — all grandsons of Nanay Gloria. Nanay Gloria claims that the Iglesia has, at present, more than 100 members. But on the several Sundays that I went there to observe their group, I noticed no more than 20 in attendance.

    The interior of the church is simple in appearance. Save for a few wooden chairs reserved for visitors, there are no pews of the kind usually seen in Catholic churches. In fact, the Iglesia has no need for benches: all the members kneel throughout the worship rituals.

    The center of attention is the elevated altar in the shape of a triangle which displays a motley array of pictures, posters, and statues, all depicting Rizal or his other “personalities.” I learned that in the past, Rizal — according to Nanay Gloria — appeared to them as an old white-bearded man (whom they call Apo Asyong), and as an aged woman (whom they call Inang Adarna). But one should not be confused. They are all Dr. Jose Rizal!

    Hanging on the walls of the church are numerous posters listing the many teachings of Amang Rizal. Some of them contain quotations from Rizal's great body of writings, the stanzas of Rizal's "Last Farewell", and curiously, a poster with Rizal's "Ten Commandments.”

    At the start of their Sunday service, the congregation offers a prayer while genuflecting in front of the altar. Then with their right hand upon their bosoms, they sing the Philippine National Anthem in two versions: the original version and another with different lyrics praising Rizal and other Philippine heroes. A series of chants follows, led again by Nanay Gloria. Most of what they sing are about love of country and fellowmen, as well as love for Apo Asyong, Inang Adarna, and Amang Rizal.

    Meanwhile, I observe their rituals at the far end of the pew, jotting down notes and taking pictures. After an hour of prayers and chants, Nanay Gloria suddenly stands up, faces the group and begins a long monologue exhorting the members to keep the faith, to worship Amang Rizal, and never to be influenced by other religions. She calls her flock "mga anak" (my children) even though most of them are ladies of her age. "Mga anak, huwag na huwag ninyong kalilimutan ang mga aral ko! Ang inyong mga pagtitiis ay nakikita ko," (My children, do not ever forget my teachings! I see all your sufferings").

    All the while, the Iglesia members are on their knees, listening attentively with their eyes closed. They all look as though they've been turned to stone by the mighty rhetoric of Nanay Gloria. Then all of a sudden, Nanay Gloria shifts her gaze to me, pointing her finger in my direction.

    She utters in a fierce tone: “Why are you here?”

    Surprised by Nanay Gloria's question, I meekly reply that I am interested in learning about the indigenous religions of the Philippines. And being an admirer of Rizal, I am fascinated that their Iglesia worships Dr. Jose Rizal.

    Nanay Gloria is visibly pleased by my answer. “What do you think of our group?” she asks. I say they are a very religious and nationalistic people because of their reverence of Philippine heroes like Rizal, Bonifacio, and Mabini.

    “You are correct,” she says. She then approaches me and raises her right hand to bless me. She touches my head, telling me I am fortunate to have traveled to this remote barrio because it pleases Amang Rizal, and that I am now blessed. Then she turns to her flock once more and delivers another long and rambling speech -- somewhat disconnected but with only one important message -- that they should forever love God in their hearts, and to follow the 10 commandments. At one time she tells them they should be thankful I visited them, coming from a place as far away as Manila.

    Nanay Gloria as Rizal's medium

    It is only after the sermon that I learn it was no longer Nanay Gloria who was talking. The Iglesia members revealed to me that the spirit of Amang Rizal possesses Nanay Gloria every time she delivers her sermons. It was not Nanay Gloria who touched my head and blessed me. It was Amang Rizal. I have been blessed by Amang Rizal himself. Indeed, after the sermon, Nanay Gloria appeared more like her usual self: gay, smiling, and humble. She no longer had the fierce voice and penetrating gaze of God the Father.

    After their rituals, they all stand up, bow to the altar and rest on the wooden chairs. They all smile at me, bowing, their hands on their chests as as sign of respect. Meanwhile I focus my attention on the numerous Rizal statuettes and photographs on the altar. At the center is the bust of an old man. For me, the figure doesn't resemble Dr. Rizal in any way, even if I mentally added years to my personal image of the hero. The old man has a shawl on his head and sports a long white beard. One cannot mistake his identity because written below the statue is his name: Apo Asyong. His full name, according to Nanay Gloria, is Senor Don Ignacio Coronado.

    Fascinated, I ask Nanay Gloria who Apo Asyong is. She answers that Apo Asyong is God the Father. I complain to her I get confused over who God is: Rizal or Apo Asyong?. She taps my forehead as if to teach a young kid: “Don’t be confused!” she says. “Amang Rizal and Apo Asyong are one person! Sometimes Rizal appears as Apo Asyong, sometimes Apo Asyong appears as Amang Rizal. Amang Rizal is the Diyos Anak, Apo Asyong is the Diyos Ama! But they are one!”

    And then I ask the inevitable question: “Then who is the Diyos Ina?”

    Nanay Gloria, now visibly exasperated by my ignorance, taps my forehead again: “Inang Adarna is the Diyos Ina!” She giggles through her revelation as though it were the most important thing she has ever said to anyone.

    Forgive me, my dear Nanay Gloria, I say. “So Inang Adarna is also Amang Rizal who is also Apo Asyong, am I right?”

    “Yes!” she said. “They are the Holy Family! Three persons in one God!”

    I close my eyes to ponder on what she is saying. I realize that this is the reason they call themselves the Iglesia Sagrada Familia or The Church of the Holy Family, because in their belief, God consists of a family: God the Father, God the Mother and God the Son. The Most Holy Trinity.

    “Have you seen Apo Asyong?” I ask Nanay Gloria.

    “Yes. I lived in his house when I was still a young woman” she says proudly.

    The story of Apo Asyong

    Don Ignacio "Apo Asyong" Coronado, I later found in my research, lived in Sitio Aplaya, some three kilometers away from Calamba town proper (about seven kilometers from Rongot). Apo Asyong's house, though old and very dilapidated, continues to stand to this day, now inhabited by his numerous grandchildren and great grandchildren.The house also doubles as Apo Asyong's temple, where many Rizalistas still come to worship. In Sitio Aplaya, many old residents still remember Apo Asyong as a good and helpful man. Many also believed that he was a man with mysterious powers.

    Born on February 2, 1890 (?), Apo Asyong preached in the 1940s that he was the real Dr. Jose Rizal -- and that the man killed by the Spaniards in 1896 was a fake, a Rizal double. Apparently, many people believed him, and he was thus worshipped by followers (including Nanay Gloria and the entire Sagrada Famila sect) as the true living Jose Rizal. Interestingly, Nanay Gloria and Apo Asyong's grandsons never use the term "death" when referring to Apo Asyong's demise. Instead they prefer to call his death as "paglisan" (leaving), which of course denotes that he would be coming back in the near future. "Apo Asyong will never die, just as Amang Rizal did not die in Bagumbayan," she told me.

    Apo Asyong's core teachings are basically the same as those preached by Rizal -- love of God, love of fellowmen, and love of country. Apo Asyong -- if we are to believe the testimonies of his followers -- has the power of teleportation and can be in several places at the same time. Like Rizal, he is also said to be a linguist -- fluent in all the major languages of the world, even though there is no record he had had formal studies in schools. When Apo Asyong and his followers would go to Calamba town proper, they would visit the old Rizal house (the reconstructed house, actually) and he would point out his bedroom, his sisters' bedrooms, as if he was indeed the young Rizal who lived there in the 1860s.

    Apo Asyong suddenly fell ill in the morning of 21 December 1957, and died at midnight. His remains were interred at the public cemetery in Lecheria Hill, the place where Rizal was believed by Rizalistas to have spent his childhood and youth. His grandchildren still faithfully keep his old things -- his clothes, his pillow and bed (still arranged in the same way as when he died), his pipes (he smoked tobacco), and his old tumba-tumba chair. They regard him as God the Father.

    There is one extant photograph of Apo Asyong, and it is always prominently displayed in many Rizalista temples that worship the kindly old man.

    One rainy Sunday afternoon (after attending the worship rituals for Apo Asyong), Joseph, one of Apo Asyong's grandsons, asked me if I wanted to visit his lolo's mausoleum in Lecheria. Although it was raining hard, I agreed to go to the cemetery to visit the tomb of this mysterious man. The grandson assured me it was still existing and that the family visited it annually every November 1. Because of the heavy rains, we slushed through mud, clambering atop old tombs to individually search the tombs and mausoleums, but alas, we couldn't locate Apo Asyong's final resting place. "It was just here," Joseph told me, pointing to an empty plot in the cemetery. "He already took his bodily remains to heaven," Joseph concluded.

    Fascinated with this mysterious man, I asked Nanay Gloria how they first came to know Apo Asyong. In reply, Nanay Gloria told me a fantastic story of how Apo Asyong built their church. It was not easy. They lived a very difficult life. Many people accused them of being lunatics. But the people just didn’t know what Nanay Gloria and her group had gone through - their travails and hardships just to build this church. They persevered because they knew Amang Rizal/Apo Asyong would reward them in the near future.

    The Beginnings of the Iglesia Sagrada Famila

    It all began many years ago in a place not so far away….

    There was a war; the Second World War. The exact date was October 1942. Mr. Danny Bibat, a U.S. Navy skipper, and the elder brother of Nanay Gloria, was a commander of an American vessel in the Pacific Ocean. His vessel was torpedoed by a Japanese battleship. Fortunately, Danny and some of his men were able to jump out into the sea before the ship floundered. After a few days of floating, when Danny and his men were so exhausted they were ready to give up and sink in the water, something mystical happened. A low-lying cloud appeared before them. Perched on top of the cloud was a half-body figure of a mysterious bearded old man. The old man rescued them and pulled them all to shore. Soon after, the old man, without saying a word, vanished.

    After the war, Danny retired from the Navy and lived a quiet life in Tatalon, Quezon City. In 1951, an old woman came knocking on his door, looking for him. After introducing himself, Danny was told by the woman that an old man wanted him to go to Sitio Aplaya in Calamba, Laguna.

    Without hesitating, Danny went with the old woman to Sitio Aplaya, Calamba, where he came face to face with an old man -- the same one who rescued him from the sea mishap during the war. But this time, the old man was no longer in the clouds. He no longer looked like a sacrosanct apparition, but a man of flesh and blood. And, to Danny’s amazement, he looked like Dr. Jose Rizal!

    The old man showed Danny a picture of all the Philippine national heroes and asked Danny if he could identify the one that resembled the old man. Danny pointed to the photo of Dr. Jose Rizal. The old man affirmed he was indeed the patriot presumed executed in Bagumbayan many years ago. "I am not a ghost, Danny. I am real," he said.

    Danny prostrated himself before the old man, who was none other than Apo Asyong, crying: “My Lord, I have been looking for you for a long time! Why is it only now that you called me?”

    Apo Asyong replied: “The time has come. I called you because you will now prepare the New Jerusalem in Sitio Rongot. You will pave the way to start the new Holy Land. Bring your family and live there."

    Danny thanked Apo Asyong and immediately went to all his relatives in San Nicolas, Pangasinan. He told them they were going to live in the new Holy Land in Calamba, that it was a beautiful place, and that it will be the new paradise. Danny succeeded in convincing his family and relatives. Altogether, 13 families, including friends and their families, joined Danny in the exodus to Rongot. They sold their houses and farms in San Nicolas. Then they hired a truck and headed to the sitio. Everyone was excited and looked forward to settling in the Promised Land.

    But they soon found out the journey would be no picnic. On a stop to San Luis, Pampanga, they were robbed and lost all their money and possessions. With no money to buy food, they remained for an indefinite time in San Luis, until six of the families, penniless and without food, decided to go back to Pangasinan, hitchhiking and walking (the truck abandoned them). Seven families decided to stick with Danny and continue their exodus to Sitio Rongot. Nanay Gloria was a young woman then, but she remembers the hardship they endured.

    “We neither have money nor food. But we thought it was God testing us to persevere. We knocked on every door begging for food, and very few people helped us. We only ate lugaw (porridge) everyday. We sold many of our personal belongings to buy food.”

    After several months of walking and begging, they finally reached Sitio Rongot. What they saw devastated them. Sitio Rongot was not the paradise they thought it would be. Instead, it was total wilderness, with tall weeds growing about everywhere in the place.

    “We thought we could not live here,” remembers Nanay Gloria. “It was all weeds and tall grasses here. No one lived here then, except maybe snakes and field rats. But still we persevered. Apo Asyong told us that Sitio Rongot will become the New Jerusalem and the new Holy land. So we decided to stay. We cleared the area and turned this place into our home. And look, this is now a community!”

    They decided to build their church, the Iglesia Sagrada Familia, on the very banks of the Laguna de Bay. Most of the materials they used to build the church were either donated to them by the more affluent members of the Iglesia, or by local politicians asking for votes during elections. Even the posters, pictures, and statues of Amang Rizal were donated to them by various people. They really could not afford them.

    "We are poor,” says Nanay Gloria, "but there are many people being used by God to help us and this church.” Meanwhile Amang Rizal was appearing to them frequently. Sometimes he is just like what is seen in his numerous pictures — wearing the double-breasted coat and carrying the Noli me Tangere in his left hand; other times as an old man or Amang Rizal appears; or even as Apo Asyong, or an old woman, Inang Adarna.

    To earn a living, they harvested kangkong and kamote and sold them in town, walking the five-kilometer road and carrying the crops on top of their heads. The men built small bancas so they can fish at the Laguna de Bay.

    Soon, their living conditions improved, but not much. Nevertheless, they consider themselves blessed to have been chosen as the first residents of the Holy Land.

    Nanay Gloria as the New Spiritual Leader

    In 1972, Danny Bibat passed away and Gloria Bibat became the head of the Iglesia Sagrada Familia. To prepare herself for her new role as spiritual leader, Nanay Gloria fasted for 40 days, subsisting daily on small bread and a cup of tea. It was what she termed as "sacrificio”, to cleanse her body for her new spiritual life.

    "I became very thin," she said. "But I survived because of God's will." She then assumed her role as the leader of the church. From then on, she was called Nanay Gloria (she was called Ate Gloria before).

    Although she is now 84, Nanay Gloria still looks strong. She attributes her long life to the blessings of Apo Asyong. She never cuts her hair although it is now very thin because of her age. She still walks the five-kilometer distance road from Rongot to town proper. In her chest she keeps an anting-anting medallion which she says was given to her by Apo Asyong.

    “This is the medallion of the Impinito Dios," she says while showing it to me. “Impinito Dios is the highest God. He went down to Earth to save us. He became Jesus, Apo Asyong, Inang Adarna, and Amang Rizal”

    “Do you all keep an anting-anting?” I asked.

    “Yes. Look at us; we are still strong despite our age.”

    By now, though, many of the original members of the Iglesia have died from old age. There are now only about 20 original Iglesia members still living--all belonging to the original seven families who first came to Rongot. All the ladies are in their 80s and 90s now--widows who have outlived their husbands. Some, like Lola Aria, 87, are spinsters. They all wear long white dresses that reach their ankle. Like Nanay Gloria, they never cut their hair. Every one of them still diligently attends the Sunday worship service for Amang Rizal. Sometimes, they bring along their apo to the worship rituals. They teach their grandchildren to worship Apo Asyong and Amang Rizal. Aside from these youngsters, there are no new recruits to the Iglesia.

    “We don’t attract new members,” Nanay Gloria tells me “It is better we are few. We are few but we are true to our faith and that’s the most important thing. But if someone wants to become one of us, he or she is most welcome.”

    While the Iglesia is not keen on recruiting new members, Sitio Rongot, meanwhile, is attracting new settlers. The sitio is a public land, and the growth of Calamba's population forced some locals to migrate to Rongot. With more people now living in Rongot, there are also more religious groups now preaching their respective religions such as the Iglesia ni Cristo, the Baptists, the Mormons, Ang Dating Daan, and the Born Again Christians.

    Now, the Iglesia Sagrada Familia has become a minority religious group in Rongot. Sometimes people--even those from the new religious groups--malign and accuse them of practicing "cult" or kulto worship.

    “They call us kulto,” resents Nanay Gloria. “Don’t they know the meaning of kulto? It means worshipping a human. But we do not worship a human. We only worship God. We worship Jesus. We worship Apo Asyong. We worship Amang Rizal. Amang Rizal is not a man. Ang Amang Rizal ay Diyos na totoo."

    Many people also accuse Nanay Gloria and her group as lunatics. They simply ignore the insolent remarks, shrugs Nanay Gloria. "We always remember the lesson Apo Asyong imparted to us: 'Kung ika'y sinampal sa kanan ay ibigay mo pa ang kaliwa."(If someone slaps you on your right cheek, then turn the other cheek).

    Indeed, throughout my frequent visits to them, I became an admirer of their simplicity, kindness, and humility. Their lives, basically unchanged since they first arrived here some 60 years ago, have been uninfluenced by the outside world. Their faith in God enabled them to reach the level of piousness that few of us can ever claim to achieve. Their kindness and hospitality are genuine--reflecting the old mores of the ancient Tagalogs. They may be superstitious and mystical in their beliefs, but I could never accept that they are lunatics or akulto.

    During the street parade in Calamba on 19 June 2010 to celebrate the 149th birth anniversary of Dr. Rizal, Nanay Gloria and her members joined the parade--together with most other Rizalistas in Laguna. But none of them were invited to the grand dinner that afternoon organized by the provincial government.

    For me, it reflected the general attitude of people towards the true Rizalistas. While local and provincial politicians--who instantly became "Rizalistas" on the birth anniversary of Rizal to further their political careers--were served in the grandiose dinner, the genuine Rizalistas were on the side streets seeking shade from the heat of the afternoon sun--eating their own packed lunch or sandwiches and drinking softdrinks from a sari-sari store.

    How come the Rizalistas are never ever given importance during the anniversaries of Rizal? Instead they are treated with indifference or mockery because of their obsessive love for the national hero. But in my heart of hearts, I feel compassion for them. The true Rizalistas--like Nanay Gloria and her group--are forever ignored by the Filipino people.

    I have often associated myself with the Rizalistas because I felt that they are true to their beliefs. Though I myself may find it bizarre that they worship the hero, I nevertheless respect their beliefs. And I find that they are closer to my heart than other worshippers, including those from my own Catholic religion. I always, ALWAYS want to understand them.

    And so with some trepidation, I ask Nanay Gloria the question that really brought me to Rongot: ‘Why do you worship Amang Rizal?”

    “Because He is God,” she replies. "Amang Rizal is the Savior of the Filipino people. He saved us from the Spanish oppressors.”

    "So where is Amang Rizal now?” I ask.

    “He’s living somewhere in the forests and caves of Mount Makiling . But he will come back soon. He will make this place--Sitio Rongot-- the center of his kingdom!”

    Meanwhile it is already getting late and I know that Nanay Gloria also needs to rest. I thank her for her kindness and hospitality. Then I take from my backpack my secret gift for her: A small statue of Amang Rizal I purchased from an antique shop many years ago. I thought it would be the best gift that I could give to the Suprema and her members.

    “Here,” I offer, “is my gift to you for your kindness to me,” handing to her the small bronze statue.

    Nanay Gloria beams when she sees the little statue of Amang Rizal. Her eyes well with tears. Then she motions to her members to look at it, all women in their octogenarian years.


    “It’s beautiful!” they say in unison. Some of them also cry upon seeing the miniature figure of Amang Rizal. They caress the statue like a little baby. Then holding the statue together with their hands up in the air, the old ladies chant:

    Amang Rizal! Amang Rizal! Amang Rizal! Aming Diyos! Aming Diyos! Aming Diyos! Ikaw ang simula at ang wakas, ika’y aming pinupuri!!! Amang Rizal!!”

    I, too, am moved by the spectacle. Then I approach and hold the statue with them, chanting with them.




















    ALL PULSE GENERATORS IN CHEST XRAY ARE NOT CARDIAC


    Since it has become universal not  to receive clinical notes for any Chest Xray, it has become that much more difficult for the residents and consultants to become aware that all pulse generators of the chest are  not cardiac pacemakers. This an example of chest X ray done with history of cough  with DBS generators with leads travelling cranially. Submitted by Dr MGK Murthy.


      (A) DBS- Deep Brain stimulator (DBS) is used to stimulate and control the various movement disorders particularly dystocia and parkinsonism. It consists of an electrical pulse generator and insulated wires.  Electrodes extend from the thalamus subcutaneously down the patient's neck and connect to a pulse generator usually located under the clavicle

    (B) Others include
    ·   Repetitive  vagal stimulator for refractory seizures and more recently  for intractable hiccups
    ·    Spinal cord stimulator -Placed for intractable pain management  with leads at D9 to L1 in epidural space and generator beneath the abdominal skin laterally
    ·    Gastric stimulators for gastroparesis to enhance emptying
    ·     Urinary bladder stimulators
    ·    Diaphragmatic stimulators with receivers beneath the domes and leads along the phrenic nerves paraspinally
    ·     Bone stimulators in close contact to promote healing  

    Sunday, May 15, 2011

    Post Spinal Anesthesia Intramedullary Injury


    A young lady  2months after undergoing Caesarean section  complaints of both lower limbs weakness with non-specific distribution . In he history, during the  epidural anesthesia for caesarean, she experienced severe shooting pain in to the Right lower limb, which resolved with medication. MRI shows longitudinal  ill defined  cord signal abnormality possibly hydrosyrinx from D11 to conus with no bleed, expansion or arachnoiditis  or epidural collections. Submitted by Dr MGK Murthy and Mr Hari Om.




    Epidural anaesthesia  is one of the safest procedures, but occasional complications are known. This case represents possibly

    (i) inadvertent injection of local anesthetic  in to low lying   variant radiculomeduallry artery  branch, feeding the anterior spinal artery , leading to vascular injury

    The other possibilities include
    (ii) direct intradural administration of LA leading to chemical injury
    (iii) direct long needle injury to the cord in high injection
    (iv)hypotension injury to the cord during the procedure
    (v) post infective sequelae (myelomalacia)
    (vi)unusual epidural venous plexus injection leading to venous hypertension and infarction
    (vii) unrelated to the procedure and incidental finding due to other  causes including trauma, Chiari malformation etc

    Evolution of Radiology Learning

    According to an article in Academic radiology, Vol. 14, No. 9. (September 2007), pp. 1113-1120-"Currently, residents prefer the Internet when researching a question, with Google as the Web site most commonly used. Case review or requisite books are more commonly used than are traditional textbooks. Radiology resident learning has rapidly shifted from traditional textbooks and journals to the Internet and short case review books."

    Given the vast resources available on the internet these days and modern radiologists having so many tools at hand from smart phones, to ipads to notebooks.. this hardly is surprising.

    Do you think text books will soon be thing of the past? Comments and opinions requested.

    Monday, May 9, 2011

    Ankle Fracture For Radiologist

    Only 15% show fractures.  Ottawa rule says , weight bearing immediately after injury or for the radiograph usually excludes severe bony injury.  Radiographs usually AP, Lat and Mortise view(15 to 20 deg internal rotation view)

    • Look for (apart from routine bones, alignments ,and soft tissues and tibial plafond ) FLOAT-most commonly missed fractures, Fifth Metatarsal base, Lateral malleolus, Os trigonum or posterior malleolus, Anterior Process of calcaneum, and Talar dome





    Radiographic evaluation

    AP View

     Medial clear space of >3mm=deltoid/syndesmotic strain

     Tibifibular space<6mmis normal

     Standing AP, syndesmotic widening>3mm=syndesmotic strain


    Mortise View

     Lateral clear space>2mm=syndesmotic strain

     TibioFibular overlap should be normally>1mm

     Normal medial clear space <4mm OR difference between medial and lateral <2mm

    ALL displaced medial malleolar fractures and oblique fibular fractures proximal to joint by2-3 inches will have ligamentous injuries. Teaching points by Dr MGK Murthy.