PACStacker for Power Point

"Khanna et al have developed PowerPoint add-in that facilitates the creation of stackable image sets in a simple and intuitive manner, permitting real-time scrolling, editing, and manipulation of imbedded image stacks. Contrast and brightness adjustments, cropping, and linking are supported. Once created, the PowerPoint presentation can be viewed without hardware or venue limitations on any computer, without reinstallation of the add-in."

Reference-

DOI:10.2214/AJR.07.3757

AJR 2009; 192:W71-W74

A Visit to an Indian Temple in Laguna

The 5th of January is an important holiday among the Indian Sikhs around the world, as it commemorates the birth anniversary of Sikhism's tenth Guru, the Indian Lord Sri Guru Govind Singh Ji (1666-1708).

In the Philippines, the Filipino-Indian community celebrated the holiday on the 3rd of January (a Saturday) with a worship service in the Gurdwara (temple) of Biňan, Laguna. The worship service was followed by a street procession, and distribution of foods to the Filipino community.

I have been invited by an Indian friend (whom I first met in the Khalsa Diwan Temple in Manila), to participate and photograph the festivities. Since Biňan, Laguna is only a few hours bus drive from Manila, and since the occasion fell on a Saturday in which I was free, I accepted the invitation. In fact, I felt very honored to have been invited to such an important occasion.

And so, on the morning of the 3rd of January, I was sitting on a bus on the way to Binan, Laguna. Kumar would be following later, but we agreed to meet at the Gurdwara(temple). He will be coming late because of some preparations. He gave me the directions to the Gurdwara. I would be riding in an Alabang-bound bus. I would debark in Alabang and then I would be riding in a Binan-route jeepney, which would bring me to the town proper. In the town proper, the Gurdwara is only a few kilometers away, and there are tricycles around that can bring me there in a few minutes.

I arrived in Alabang at around 8 in the morning, alighted from the bus, and hailed one of the Jeepneys with the sign Binan, Laguna. There wasn't a traffic except for some congestion near the Pacita Complex in San Pedro, Laguna.

Philippine jeepneys

The Jeepney I was riding on was only half-full, and our driver was speeding and seemed in a hurry to earn early money. One of my fellow passengers- an old lady- complained that with our crazy speed, we might as well be headed to the cemetery instead of Binan, Laguna. The driver seemed unaffected by the remark, and continued on his murderous speed, which if my estimation is correct, was in the 90km/hour. In the Philippines, riding a Jeepney is like Russian roulette. You never know if it's going to be your last.

I was seated at the far end of the long Jeepney seat, near the entrance, and I found it a good vantage point to take some pictures. Some of my fellow passengers were amused and asked me if I was a press. I said that I was only taking pictures for souvenirs. I always get embarrassed whenever people ask me if I work in the press. It seemed that in the Philippines, all people with professional cameras are already considered working for the press. I cannot tell them that the pictures are exclusively for this blog, because by then, there would be a lot of explanations as to what a blog is. And I was not prepared to give a seminar.

Meantime, our crazy chauffeur was picking up more passengers, and the seats were becoming occupied. I have to squeeze myself tightly between two fat women so they can seat comfortably while I languished in an uncomfortable position. I handed my 12 peso fare, and fellow passengers near the driver handed my money.

After thirty minutes, our Jeepney arrived in the town proper of Binan, Laguna. Thankfully, our murderous ride was over and we did not head to the cemetery as the old woman had predicted.

Binan is only a small town, but with very clean and well-paved roads. I would have loved to explore this lovely town, but I needed to arrive early in the Gurdwara, which was still one ride away by motorcycle. Public motorcycles in the Philippines are called tricycles. It is just a regular motorcycle but with a small cab appendage on the side for passengers.

Street scene in Binan. I took this picture while riding the tricycle.

After 5 minutes of tricycle ride, I arrived in the Gurdwara just in time when the worship service was already about to start. I didn't know anyone here, and I arrived as a complete stranger, with no one to give me a flower or a red carpet entrance. I called Kumar that I was already in the Gurdwara, and he said that he was already in San Pedro, and would be arriving in about a few minutes.

There were many Indians around and I hoped I look like an Indian, too. It seemed that in this place, all people are Indians. Indeed, I really thought that I was in a mini-India at that time. I took out my camera and took some pictures of the sceneries. Some Indian men probably thought that I was a professional photographer from the press, and called me for some pictures. Like the Filipinos, the Indians are very easy to photograph as they like to pose in front of the camera. It doesn't matter if you're an acquaintance or a complete stranger.

The Indian Gurdwara in Binan is called
Sri Gru Nanak Dev Ji Temple, named after the first Sikh Guru

Afterwards, one kindly Indian elder said that I should go inside the temple to take pictures of the worship service. I removed my shoes and covered my head with a handkerchief, as was the custom, and entered their holy temple. At this point, I felt like I was gate-crashing to an important sacred occasion. Many Indians were seated listening to the sacred chants of the Gurus seated in front of the altar. It was a most divine place, and I felt that my camera was an unworthy equipment here.

I bowed to the Gurus and they nodded. Some Indians looked at me, a Filipino, wondering perhaps why I was there in the first place. I didn't look anywhere near like an Indian. I have the typical Filipino look. I sat at the far end of the worship hall, thinking if I can take photographs. Then one Indian seated next to me pulled out a digicam from his pocket and started taking photographs. I made a sign language clicking an invisible camera in front of my face if I can also take photos with my camera, and he nodded.

And so I started taking pictures. I became bolder each time I clicked my camera, and I even used flash. No one seemed to be bothered. Everyone was just listening to the sermon, which I couldn't understand because it was in Punjabi language. Suddenly, all Indians stood up for the arrival of the High Priests. I also stood up and took photos of the High Priests.

Meantime, three elder turbaned Gurus waved their hands, motioning me to come over to them. They have some of the most serious look I have ever seen and I thought that if I broke a protocol, I am willing to meet the punishment, whatever it is. I came over, with beads of sweat already forming in my forehead. To my surprise, the three elders spoke to me in Tagalog, and asked if I could take their pictures. I said yes, and they posed together. They asked for a print out of the pictures and was quite amused when I showed them their picture in the LCD of my dslr.

Lolo requested for this portrait

At this point, I asked them if I can take more pictures of the worship for proper documentation. They said that it was alright, I can take pictures of everything, but I should not take a picture of their Holy Book, the Sri Guru Granth Sahib, as it was forbidden. One of the elder Gurus even gave me a tip that in a few minutes, the Five Holy Men will be arriving, that everyone will be standing, and I should position myself near the door to get a good angle for pictures.

After a few minutes, from the corner of my eye, I saw my friend Mr. Singh arriving, attired in a garb of a holy man. It turned out he was, indeed, one of the Five Holy Men. How humble he is. We exchanged smiles, and everyone stood up to give honor to them. It's good to know I have a Holy Man as a friend.

To be continued....

Non-ketotic, hyperglycemic, hemichorea

Findings

Figure 1: CT scan reveals unilateral hyperdensity of the left lentiform nucleus and the head of the left caudate nucleus with sparing of the intervening internal capsule that corresponds to abnormal gemistocytic astrocyte production. No significant abnormal enhancement is identified.
Figure 2: MR images demonstrate hyperintense T1 and hypointense T2 and diffusion weighted image signals in the same distribution as the CT abnormality. There is no significant abnormal enhancement and no mass effect.
Figure 3: Follow-up imaging performed 14 weeks after initial presentation demonstrates preserved high signal in the left basal ganglia without mass effect or enhancement. T2-weighted signal has changed from low to high intensity, perhaps representing interval gliosis.


Diagnosis: Non-ketotic, hyperglycemic, hemichorea


The differential diagnosis for the new-onset hemichorea includes: stroke, hemorrhage, tumor, infectious disease, neurodegenerative disorders and non-ketotic, hyperglycemic hemichorea.
Particular to the diagnosis of NHH, the characteristically unilateral transient extrapyramidal motions resolve following glycemic control.
Cerebral images of these patients consistently have shown unilateral CT hyperattenuation and unilateral MRI T1-weighted hyperintensity in the striatum contralateral to the side of the transient, extrapyramidal motion disorder.
Typically, an elderly diabetic patient presents with new-onset hemichorea as well as glucose levels ranging from 400 to 600 mg/dl with an HBA1c greater than 13%.

Non-ketotic, hyperglycemic hemichorea (NHH) was first described by Rector, et al. in 1982. Thirty-three cases of NHH have been identified in our recent review of literature. The most commonly reported location of a lesion has been in the putamen. Kumral, et al. have suggested that the anterior putamen needs to be involved for transient extrapyramidal motions to occur. The distinct imaging findings are hyperattenuation on CT and hyperintensity on T1-weighted MRI. This Case in Point’s images concur with these distinct image findings.

The onset of NHH has been attributed to petechial hemorrhage with blood-brain barrier breakdown, cerebral ischemia leading to dysfunction of the GABAnergic projection neurons and gliosis. Blood glucose levels of 159 to 647 mg/dl have initiated non-ketotic hyperglycemia resulting in hemichorea. More commonly reported values exceed 500 mg/dl.

There is accumulating consensus on the pathophysiology of NHH. Human autopsy, animal studies, human biopsy and MR spectroscopy evidence that NHH results in mild infarction with gliosis and concurrent accumulation of pathologically swollen, nucleus-eccentric astrocytes, known as gemistocytes. MRI findings have been attributed to gemistocyte deposition along axons. Rat model and human autopsy histopathology have revealed T1-weighted, hyperintense, gliotic brain tissue with abundant gemistocytes.

This Case in Point documents new hyperintensity in the areas of previous hypointensity on follow-up T2-weighted MRI and FLAIR images. It is plausible such images represent areas of delayed gliosis or scar tissue formation.

The Dragon Dance

Like a true living mythical monster, the Chinese Dragon danced its way into the heart of Manila Chinatown to highlight the Lunar New Year celebrations.

In Chinese culture the Dragon is said to bring good luck and prosperity. It is also a symbol of power, dignity, strength, fertility and wisdom. Although the Chinese Dragon may have a frightening appearance, it has, however, a benevolent disposition. In Imperial China, it is a long time favorite symbol of the Emperors, and many palaces have dragon designs and representations in them.

The Dragon Dance is performed by a team of highly-skilled dancers. The number of dancers depends on the length of the Dragon itself. The dancers carry the Dragon (made of fabric) on poles as it swirl, twist, and chase the giant pearl it is forever guarding. The dance must be carefully choreographed as a mistake by even one of the dancers can spoil the performance. I can say that all the Dragon Dances I have seen in Manila Chinatown are as perfectly performed as any can be.

Rotator Interval Tear-MRI

There is evidence of fluid collection in the subscapularis and subcoracoid bursa, in relation to the coracobrachialis and biceps tendon, in relation to anterior spect of the supraspinatus tendon and superior aspect of subscapularis tendon. . There is altered signal intensity in the region of rotator interval in relation to the anterosuperior aspect of the glenohumeral joint. Minimal fluid in identified in relation to the glenoid cavity. These finding can be consistent with rotator interval partial tear/injury. These tears are sometimes not accurately demonstrable by MRI arthroscopic correlation is suggested.

Fourth ventricular ependymoma with foramen of Luschka & Magendie extension

Findings

CT paranasal sinuses: Normal sinuses. Incidental note of ventricular dilatation. Partial visualization of 4th ventricular mass.
MRI Brain: Abnormal heterogeneously enhancing mass within the posterior fossa, potentially arising from the floor of the fourth ventricle and causing moderate obstructive hydrocephalus. Lobular extension of tumor via the bilateral (left > right) foramen of Luschka and foramen of Magendie.

Differential diagnosis:
- Ependymoma
- Medulloblastoma
- Atypical teratoid/rhabdoid tumor
- Cerebellar pilocytic astrocytoma


Diagnosis: Fourth ventricular ependymoma with foramen of Luschka & Magendie extension masquerading as sinusitis


Discussion

Arising from the ependymal lining of the ventricles, ependymomas constitute one-tenth of primary CNS tumors in children. 90 percent of the tumors are intracranial which helps ependymomas rank number three among pediatric brain tumors. The majority of the intracranial epenymomas are infratentorial (about two-thirds). The remaining one-third of the intracranial variety are found around the periventricular white matter.

An equal distribution has been reported in males and females. No known race predilection noted. The mean age of diagnosis is 5 to 6 years of age. The clinical presentation is often non-specific. However, it is usually related to increased intracranial pressure. The classic triad (if present) includes morning headache, relieved by vomiting and improvement with progression of the day. Other signs/symptoms can include irritability, gait problems, fatigue, personality change and declining performance at school.

Gross total surgical resection and radiation therapy are the mainstays of treatment. The fiver year rate of survival is estimated close to 55 percent. Poorer outcomes have been reported in children with incomplete resection. The exact role of chemotherapy is still under investigation.


Radiologic overview of the diagnosis

CT and MRI are the primary modalities for imaging brain tumors in children. A CT may be obtained initially. However, MRI with contrast is more useful for component characterization and tumor extension.

Regardless of imaging modality, the best diagnostic clues include inhomogeneous appearance and pliability. The tumor is known for its ability to squeeze through the fourth ventricle into the cisterns. Another important diagnostic feature is ill defined interface with the floor of the fourth ventricle.

On CT, calcifications are present in half of these tumors. Cystic and hemorrhagic components can also be seen. With fourth ventricular tumors, hydrocephalus can be present. The enhancement pattern is typically heterogeneous.

On MRI, an inhomogeneous appearance persists with T1 isointensity to hypointensity. The tumor is isointense to hyperintense of T2 weighted images. Areas with calcification or blood products are T1 hyperintense and T2 hypointense. On gradient images, the calcification demonstrates blooming artifact. The post contrast enhancement pattern remains inhomogeneous with overall mild to moderate enhancement. High quality sagital sequences should be included in the MRI protocol. A sagital image can help identify the point of origin (floor of fourth ventricle = ependymoma, roof of fourth ventricle = medulloblastoma). MR spectroscopy cannot reliably differentiate between this and other tumors. However, lactate and choline peak elevation is present with decrease in NAA.

Hydatid disease involving the brain (Echinococcus granulosus infection)

Findings

T1 (Figure 1) and T2 (Figure 2) weighted MR images demonstrate two homogeneous cysts with signal intensity similar to cerebrospinal fluid and very thin-walls (yellow arrows). There is significant mass effect on the lateral ventricular system.
Contrast enhanced MRI (Figure 3) shows lack of enhancement of the cyst walls.


Diagnosis: Hydatid disease involving the brain (Echinococcus granulosus infection)


Intracranial granulosus echinococcosis occurs in only approximately 2% of cases of hydatid disease.
E. granulosus infection of the brain presents with one or more homogeneous, thin-walled cysts.
Cyst signal is isointense relative to cerebrospinal fluid.
The cyst wall typically lacks gadolinium enhancement.
Usually there is no perilesional edema.

Hydatid disease is a worldwide zoonosis produced by the larval stage of the Echinococcus tapeworm. The two main types of hydatid disease are caused by E granulosus and E multilocularis. E granulosus is the more common type, whereas E multilocularis is less common but more invasive, mimicking a malignancy. It is commonly seen in the great grazing regions of the World, particularly the Mediterranean region, Africa, South America, the Middle East, Australia, and New Zealand.

Dogs or other carnivores are definitive hosts, whereas sheep or other ruminants are intermediate hosts. Humans are secondarily infected by the ingestion of food or water that has been contaminated by dog feces containing the eggs of the parasite.

Intracranial granulosus echinococcosis occurs in only approximately 2% of cases of hydatid disease, typically involving the cerebral parenchyma, especially the parietal lobes, corresponding to the middle cerebral artery watershed territory. Intracranial subarachnoid spaces are the second most common location of the disease in the CNS, although their occurrence is far less frequent. Cases of cerebral aqueduct cyst, gigantic cyst arising from the diploe of cranial bones with intracranial extension, and intradural spinal hydatid cysts have been reported. Cysts are usually single and may be unilocular or multilocular. Cerebral hydatid cyst is more common in children than in adults.

At MRI, cerebral hydatid disease generally appears unilocular and is isointense relative to cerebrospinal fluid. The lack of surrounding edema and the marked mass effect make it easy to distinguish cerebral hydatid disease from abscess and cystic tumor. The presence of a hypointense rim, especially on T2-weighted MR images, is characteristic of hydatid cyst of the brain. Cerebral hydatid cyst is generally solitary but may be multiple when it ruptures spontaneously or due to trauma or surgery. Multivesicular cysts are rare in the brain. Calcification occurs in less than 1% of cases.

The Lion Dance in Manila Chinatown

The Lion Dance is an ancient dance performed in traditional Chinese celebrations, in which the dancers--attired in Lion's costume--mimics the Lion's movements in a free form. The mythical lion is often regarded as a guardian in Chinese culture, thus many marble and stone lion representations are often to be found guarding Chinese palaces, houses, and tombs.

Stone Lions serve as guardians to many Chinese structures

The Lion dance has a long history dating back to more than a thousand years. Records in scrolls found in Imperial China depict drawings of the Lion dance being performed for the pleasure of the Chinese Emperor. Apparently, there are two styles of the Lion Dance, the Northern Style and the Southern Style. The Northern Style is being used mostly in imperial courts (so this already a defunct style), while the Southern Style is usually performed to drive away the evil spirits, such as the ones performed during the celebration of the Lunar New year.

The Lion Dance is usually composed of two Lions--performed by two dancers for each Lion. The dancers are men costumed in Lion's appearance, one is holding the head and front limbs, while the other is holding the lion's torso and the hind limbs. Amidst explosions of firecrackers and drum rolls, the Lion dancers perform a fascinating dance meant to drive the evil spirits away. As a token for their performance, the business establishments give the Lion dancers money in red packets hanging on top of their doors, to be picked up by the Lion dancers during the performance.

I have often witnessed Lion Dances on many a Fiesta around Manila(I witnessed one during the Quiapo Feast Day, and another during the Tondo Fiesta). But I can say that the most beautiful and theatrical Lion Dances are to be witnessed during the Chinese Lunar Year celebrations.

The Lion Dance I covered in Chinatown last New Year celebrations was truly a spectacle of pomp and circumstance. The Lions danced joyfully in fantastic rhythmic harmony with the drum rolls and firecrackers. The explosions are ear-shattering, and the smoke blinding, and many spectators are covering their eyes and ears. I myself almost stopped taking photographs to cover my ears. But it was fun, really fun to see these Lions perform their ancient dance rituals for modern spectators.

Radiology Case Discussion-Musculoskeletal Radiology

There is evidence of significant synovial collection in relation to the knee joint distending the supra-patellar bursa & medial / lateral recess. Synovium appears thickened & irregular. Fluid collection with septae is noted in relation to lateral aspect of femur with areas of signal suppression on GRE suggestive of haemosiderin staining. Areas of altered signal intensity appearing hyperintense on T2 fat sat images noted in patellar articular surface, medial condyle of femur & tibial plateau may indicate erosive process as disease history in chronic. Degenerative changes are seen in tibio-femoral & patello-femoral articulation in form of marginal osteophytes and articular cartilage thinning. On post gadolinium scans there is evidence of synovial thickening & enhancement. Nodular enhancement is noted in area noted in relation to lateral femoral condyle.
IMPRESSION: 32 yrs old female with synovial collection with synovial thickening & collection with septae in relation to lateral femoral condyle with haemosiderin staining, contrast enhancement and erosive process in patella, medial femoral condylar & tibial plateau, early degenerative changes. D/ D Includes synovial process like tuberculosis / RA / pigmented villo-nodular synovitis. ESR / RA factor is suggested. In view of haemosiderin staining PVNS is suggested as first differential. On follow up ESR and mantoux were done and were found to be negative.
Your comments and discussions are recommended.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Philippine-Chinese New Year 2009

I made a whole-day round of Chinatown in Manila yesterday to give you the fresh images of the wonderful and unique celebrations of the Chinese New Year in the Philippines. It was a fantastic day of spectacles, photography, interviews, fun fare, and binge eating! I am pleased to report that I have eaten all kinds of Chinese dumplings, noodles, hopias, tikoys, lumpias, and Chinese soups and chicken feet! I am glad.....because I survived!

At the end of the day, I was tired and bloated, ready to slam my whole body into my bed, but before doing so, let me give you some of the images I fancied to capture yesterday. I hope that by sharing these pictures, I may have shared with you some of the happiness of the pomp and circumstance of the Chinese Lunar New Year celebrations.

Whew, what a Kung Hei Fat Choi that was!

You are now face to face with the real Ox of the Year

Many Chinese flocked to the Guan Sheng Fu Zi Buddhist Temple in Binondo, Manila to ask for the Buddhist gods for prosperity in the New Year. I learned that many of these Chinese are also Christians and Roman Catholics. One of the Catholic Chinese I interviewed said it is better in business to "ask the blessings of all the gods, Buddhist god or Christian god, the more gods the more blessings".....Well, there goes the saying, "The more the merrier!"

Just to clarify, he's not wearing a mask...


Dancing to the tune of "Oh so sexy, oh sexy....yeah so sexy!"



Fire-breating dragon...I mean, performer

The wind suddenly blew towards his face, and the flame seared portions of his face and hair. The burn was only minor and he continued to perform afterwards

Lion Dancing amidst explosions of firecrackers

More pictures to follow!