Two Lips

As I said in the last post, I was in Skagit County, Washington last week. Did you know that Skagit County is only second to Amsterdam in the production of tulips? The Skagit Valley Tulip Festival is the hottest thing in the county from April 1st to April 30th.


Acres upon acres upon acres of tulips adorn the cities... Tulips are everywhere! And I don't care what you say Colleen, I think that they are pretty! Here are some pictures from the fields....

Marchiafava-Bignami syndrome

Findings

CT Head reveals hypo attenuation of the splenium and posterior aspects of the corpus callosum. Brain MRI reveals T2 prolongation of the entire corpus callosum, subcortical white matter, medial cerebellar hemispheres, and ventral medulla. There is a small right occipital subdural hematoma. There was no post-contrast enhancement.

Differential diagnosis:
- Marchiafava-Bignami syndrome
- Lymphoma
- Demyelinating disease
- Viral encephalitis
- Wernicke's encephalopathy
- Glioblastoma multiforme


Diagnosis: Marchiafava-Bignami syndrome


Key points

MB is primary degeneration of the corpus callosum. Other white matter tracts may be involved (as in this case).
First described in 1903 by two Italian pathologists, who found necrosis of the corpus callosum on autopsy in 3 alcoholic men that had recently died from seizures.
Initially thought to be caused by excess red wine consumption, now known to be related to vitamin B deficiency, generally seen in alcoholics.
Patients present with confusion, neurocognitive defects, and seizures.
Most patients with acute symptoms go into coma and die.
Chronic symptoms are characterized / accompanied by chronic dementia.
MB typically affects the body of the corpus callosum first, followed by the genu, and finally the splenium. Other white matter tracts may be involved.
On cytopathology, the middle layer of the corpus callosum is most affected.
On MR, disease revealed by areas of low T1 signal and high T2 and FLAIR signal. Signal intensity in the body of the corpus callosum at times extending into the genu and adjacent white matter.
Lesions do not enhance, unlike in glioblastoma, lymphoma, or encephalitis.
On CT, lesions are hypoattenuating.

Osteochondral Injury-Talus

Note the lesion on the supero-medial aspect of the talus on fat sat T2 weighted images.

A Real Life Movie Star!

I was in Skagit County, Washington last week inspecting some apartment complexes. While inspecting a unit, I noticed this album.


I mentioned to the tenant that he must enjoy collecting old vinyl records. He noted that not only did he enjoy collecting the records, his voice was on them!

This is Don Doolittle!

He pointed out that since he was 16 years old, he had been acting and doing voice-over work. He's credited on the album that I saw as playing Confucius in "The Flintstones and Jose Jiminez in the Tim Machine". He also told me that he was in a movie called "Hawaii" opposite Julie Andrews, played the District Attorney in one episode of "Hawaii 5-0", and he's credited as the star of "The Creation of the Humanoids"!

San Joaquin Fortress Church

After immersing myself with the rich history of the Miagao Church, I decided to continue my historical journey to the southernmost town of Iloilo--the coastal town of San Joaquin, where they have another baroque church worth visiting--the San Joaquin Church, some 13 kilometers and 15 minute-Jeepney ride away from Miagao.

The Road to San Joaquin

It was already almost three in the afternoon when I arrived in San Joaquin, and a warm breeze of tropical wind seemed to welcome me to this lovely town as I stepped down from the Miagao-San Joaquin Jeepney I had ridden.

San Joaquin is a lovely sleepy town--very quiet and very rustic. The casual traveler may find this town to be a little laid back--a remnant of an old Philippine village of long ago. Having been accustomed to the noise and hustle of the city, I may have found San Joaquin too quiet, with only the rustling of the trees' leaves to be heard, a barking dog from a distance, and from around, the gentle whistling breeze of tropical air.

A few meters away from the main road, near the poblacion plaza is the San Joaquin Church. Built in 1869, the Church was a testament to the townspeople's sacrifices to defend their town against the Muslim pirates. Led by Fray Thomas Santaren, the townspeople, young and old, men and women, quarried coral blocks from the nearby sea to build and fortify their church. Additional blocks of limestones were quarried from the Igbaras mountains to complete the construction. The walls and beams were then finished with a smooth palisade to hide the rough texture of the sea corals.

The San Joaquin Church may hold the unique distinction of being the only Philippine church built mainly of coral stones. Like the Miagao Church, the San Joaquin was constructed not only as a place of worship but as a defensive fortress against the Muslim marauders of the 19th century.

Coral blocks in an unpalisaded corner inside the church

The Pediment. Below it is written, Rendicion D' Tetuan (Depiction of Tetuan)

The most striking feature of the San Joaquin Church is the sculptured pediment of its facade. The deep bas-relief depicts the famous Battle of Tetuan of 1859, where the Spanish Catholic Army defeated the Muslim Moroccan Army in Tetuan, Morocco. The artwork is meticulously carved by a skillful hand from solid bricks of limestones, formed together to capture the scene where the Spanish cavalry were slowly tearing down the defense of the Moroccan Muslims.

At first it seemed that the bas-relief is quite out-of-place as it does not hold any religious significance: it does not depict any saint or any religious event. But the Battle of Tetuan happened at the time when the San Joaquin Church was being planned for construction, and it was the biggest news of its day.

When the news came to San Joaquin that the Spanish Christian Army annihilated the Muslim defenders of Tetuan, Father Santaren decided to make the victory the design of the church's pediment--as an inspiration for the San Joaquin townspeople that God was with them in the battle against the Muslims--in this case the pirates. It will serve as a perpetual reminder and inspiration that they, too, can defeat the terrorizing pirates.

And indeed, from then on the San Joaquin Church had stood the test of time--both as a church and fortress, and as an inspirational structure to the townspeople of San Joaquin.

The gigantic original 1869 bell still being used to this day. Parish steward Manong Dodoy stands beside the huge bell for size comparison. The bell's clapper is as large as his head.

Like the ceiling of the Miagao Church bell towers, the ceiling of the bell tower of San Joaquin Church has already become a nest of bats. Despite Manong Dodoy's regular cleaning of bat droppings, the bell tower still exudes a malevolent odor.

The lone bell tower also served as a perfect lookout post into the sea for the incoming vessels of the Muslim pirates during the 19th century

*Special thanks to Reverend Father Manuel Villasan, Parish Priest of San Joaquin; Mrs. Helen Sernicula, Parish Overseer; and Manong Dodoy, Parish Steward. I could never thank them enough for their hospitality during my visit to San Joaquin.

It's Becoming Too Easy

Computer scientist Patti Maes spoke at a recent TED (Technology, Entertainment, Design) conference in Long Beach, California. She brought a little gadget that was created by one of her grad students at MIT, assembled from parts that any of us could buy at our local electronics store (for about $350.00).

The device allows you to use the internet anywhere using a small computer with a projector that hangs around your neck, and small (different colored) caps worn on your fingers. It looks a little cumbersome, but imagine being able to take pictures just by putting your fingers in the shape of a square or project and dial a telephone keypad onto your hand.

Imagine picking up a book at your local bookstore, placing it in front of the projector around your neck, and getting the reader rating from Amazon.com on the cover. Or when you want to find out what time it is..... Simply draw a watch on your arm.....

Right petrous apicitis (Gradenigo's syndrome clinically)

Findings

CT shows an expansile, destructive lesion in the right petrous apex, which is bright on T2 weighted MR images, and has an enhancing soft tissue component on post contrast T1 weighted-images.

Differential diagnosis:
- Petrous apicitis
- Cholesterol granuloma
- Trapped fluid
- Chondrosarcoma
- Cholesteotoma
- Lymphoma


Diagnosis: Right petrous apicitis (Gradenigo's syndrome clinically)


Key points

Synonyms for petrous apicitis include apical petrositis and confluent apical petrositis.
Petrous apicitis typically occurs via spread of infection from mastoids through air cells into petrous apex.
Clinical presentation is variable; most have otorrhea and pain. Patients can have cranial neurophaties.
In kids, petrous apicitis is often a sequelae of acute otomastoiditis. In adults, it is more often due to chronic infection.
Gradenigo's syndrome is acute otomastoiditis, trigeminal (CN 5) nerve neuritis, and Abducens (CN 6) palsy (CN 6 controls the lateral rectus muscle).
Temporal bone CT and MRI are the best imaging modalities for making the diagnosis.
On CT, findings of petrous apicitis include a destructive lesion with both cortical and trabecular loss in the petrous apex.
The best clue to diagnosis is trabecular destruction in an opacified petrous apex, which is best appreciated on CT.
On MR, findings of petrous apicitis are a thick walled, enhancing area of soft tissue with fluid in the petrous apex.
Nuclear medicine Gallium-67 scan with SPECT can improve the sensitivity for disease detection and can be used to monitor response to treatment.
Petrous apicitis was a common, severe and life-threatening infection in the pre-antibiotic era. It is now relatively uncommon.
Inflammation/infection from the petrous apex can spread to meninges and cause meningitis or can lead to cavernous thrombosis.
Treatment requires antibiotics and often surgical drainage.

Rathke cleft cyst

Findings

Figure 1 and Figure 2: Sagittal and coronal T1 weighted images demonstrate a well-defined, high-signal round structure in the suprasellar region with a low signal mural nodule. The high signal material is likely due to hemorrhagic or proteinaceous material within the cyst.
Figure 3 and Figure 4: Axial and coronal T2 weighted images demonstrate an isotense suprasellar structure with a low signal mural nodule.
Figure 5: Post-contrast T1 weighted image demonstrates no enhancement of the Rathke cleft cyst with some lateral displacement of the enhancing stalk.


Diagnosis: Rathke Cleft Cyst


Rathke cleft cysts (RCC) are nonneoplastic cysts which arise from remnants of the Rathke pouch. The cyst is lined with a single layer epithelium. On pathlogy, inflammatory changes may be present. The cyst may contain cerebrospinal fluid density material as well as thick mucoid debris, hemorrhage, hemosiderin as well as colloid. RCCs stain positively for cytokeratins.

Most RCCs are found incidentally as they are asymptomatic. RCCs can produce symptoms by causing pituitary dysfunction, visual disturbance or headache. RCCs may rarely produce sphenoid sinusitis or compress the optic chiasm and/or hypothalamus. RCCs have a slight female predominance. Some RCCs will decrease in size or spontaneously resolve while others display stable size and MR signal over time. If RCCs are deemed to be symptomatic, cyst aspiration or excision may be necessary. They recur in up to 1/3 of patients.

CT imaging characteristics of RCCs are well defined intra- or suprasellar masses which are fluid attenuation or mixed density. Cyst wall calcification is present in 10-15% of patients. The T1 appearance of RCCs varies bases upon cyst content. Five to 10% may have a fluid-fluid level. Intracystic mural nodules are present in 75%. T2 signal characteristics also vary with cyst content, with 75% demonstrating a low signal intracystic nodule. RCCs do not demonstrate internal enhancement, however the adjacent compressed pituitary enhances.

Differential diagnostic considerations for Rathke cleft cysts include:
- Craniopharyngioma (differentiated by the degree of calcification and enhancement)
- Cystic pituitary adenoma (rarely have calcification, demonstrate heterogeneous signal intensity and may demonstrate rim and/or nodular enhancement)
- Colloid cysts as well as pars intermedia cysts are also diagnostic considerations
- Other non-neoplastic cysts derived from arachnoid, dermoid, or epidermoid elements

Cops and Robbers

Check out director Adam Berg's short film titled 'Carousel'. This video was used as a commercial for a new Phillips flat-screen Cinema 21:9 television.



The cameras fly through a frozen world where bullets are flying, and cops and robbers are in an endless tug of war. The video runs full circle, back to where the video began, but with a very interesting twist. It's like watching a full Hollywood-style cops-and-robbers movie in 2 minutes and 19 seconds.

I've watched it three times now, and each time I see it I see something new! And by the way, the clown masks could not be any creepier.

Miagao Church: Views from the Bell Towers

For the first part of this post, kindly read this: The Church and Fortress of Miagao

The Miagao Church Fortress has two bell towers that in the olden days doubled as watchtowers to look out into the sea for incoming vessels of Muslim pirates. During the 18th and 19th century, the Miagao town--as well as other coastal towns of Iloilo--was being terrorized by the Muslim pirates.



The Muslim pirates came from as far as Mindanao, spread terror unto the Visayan seas and looted and burned the coastal towns. To defend the towns against these Muslim marauders, the townspeople built churches that also served as fortresses. In the neighboring town of San Joaquin (some 13 kilometers from Miagao), the townspeople even went as far as to build their church with coral stones.



I was fortunate that I had been given permission by the Parish Priest of Miagao--the Reverend Father Amadeo Escanan, H. P.--to climb inside the bell towers and photograph views from within. Normally, the parish no longer allowed the public to climb the bell towers to avoid vandalism, and also for safety reasons: the belfries' windows do not have safety screens, and the towers have already become a nest of bats. The belfries' gates therefore are always locked and the keys personally kept by Father Escanan*.

The left bell tower







The right bell tower







Sacristan Franz Montalban led me to the bell towers. The passageway was steep and narrow.

An 1839 bell. A bell such as this was usually made of old coins donated by the parishioners to the church. The coins were then melted, smithed, and fashioned into a huge bell, such as this one.

The ceiling became the nestling place for hundreds of bats. Many were flying around my head but didn't touch me. Under my feet, I felt some very soft ground. They were piles of bat droppings covering the entire floor. The repelling stench of bat droppings--from the 18th century to the present--is overpowering. Bat droppings are known to carry diseases, so don't do this at home ;)

1882 bell. This is no longer being used. Bat droppings can be seen on top.







Newer mechanically operated bells. These are the ones presently being used by the church.

The Igbaras mountains viewed from the right bell tower. These mountains were the source of the limestones that built the Miagao Church. It was a dizzying height up there in the right bell tower, and I have to be careful of my every step as there was a real danger of falling from it.

The bell towers offer a commanding view of the sea, a perfect lookout post to view the incoming pirate vessels

The entire experience of climbing the Miagao bell towers was something I could not explain beyond words. From the towers, I could visualize the town of Miagao from hundreds of years ago--when the Miagaonons were living a simple rustic life, and their church offered a solid protection from the pirates. The experience with bats flying overhead and making little noises, the flapping of their wings-made me feel being transported back to the olden times of Miagao. The beauty of it all is that the Miagao town is still the same quiet, lovely, rustic town it had always been for centuries--less the marauding pirates of the past two hundred years.

*Very special word of thanks and appreciation to Reverend Father Amadeo E. Escanan, H.P., the Parish Priest of Miagao; Reverend Father Randy G. Doromal, Parish Vicar of Miagao; Parish Secretaries Mss. Ruby Monteclaro, Geneline Felicio, and Joy Marie Nogra; and Sacristan Franz Montalban. They have all been very hospitable and helpful during my brief stay in Miagao.

Marmaduke Explained

Here’s the second of two blogs about comic sites. I hope you enjoyed the Garfield-Minus-Garfield site I wrote about yesterday. Joe Mathlete has created a blog dedicated to the worst comic of all time, Marmaduke. That’s right, the mischievous large brown dog that causes nothing but trouble.

Joe Mathlete takes the Marmaduke strip and explains the actions and comments in the strip in a humorous fashion in less than 500 words.

Here’s a couple examples:

1. Marmaduke has been given a pet frog, despite being a pet himself.
2. Marmaduke takes this pet frog on walks, complete with tiny collar and leash.
3. These walks are conducted when Marmaduke himself is taken for a walk (by his owner-man).
4. As a frog travels via hopping (rather than walking), Marmaduke is seen hopping (rather than walking) during this particular walk/hop, most likely to mimic his pet's movement rather than out of necessity.
5. Marmaduke's owner-man is seen hopping as well, despite the fact that such hopping is embarrassing (explicitly) and unnecessary/inconvenient (implicitly).
6. Marmaduke is now published in color, even on weekdays.

All of this is absurd.

Marmaduke is about to go on a date. His owner-lady makes an unfathomably distasteful double entendre about Marmaduke's girlfriend, Snyder.

Go ahead and click on the link below to check it out!

http://www.marmadukeexplained.blogspot.com

Garfield-Minus-Garfield

I'm going to blog about some funny comic sites for the next couple of days.... I appreciate Garfield for what it is.... Jim Davis created a comic strip about a cranky orange cat that loves lasagna.... Every once in a while you'll get a great Garfield comic, but even I know that it's difficult to create comic gold every day!

An artist and musician from Ireland named Dan Walsh has created a website called Garfield-Minus-Garfield. The title of the site explains everything. Dan Walsh takes the three panel strip and takes out Garfield. To tell you the truth, the strip is as least as funny, or even funnier, without Garfield.

Dan describes the site as "a site dedicated to removing Garfield from the Garfield comic strips in order to reveal the existential angst of a certain young Mr. Jon Arbuckle. It is a journey deep into the mind of an isolated young everyman as he fights a losing battle against loneliness and depression in a quiet American suburb."

Here are some samples from the site:

Click on the banner below to go to the site to see the rest of the comics: