Arnold Domingo: Tomb Caretaker

Arnold Domingo, 24 years old, a tomb caretaker at the Manila North Cemetery*, works overtime retouching the old flaking paint of a tomb's lapida, one of the many that he will repaint in preparation for All Souls Day. For each retouch, he earns fifty pesos including labor and materials (paint, brush, etc.). "Business is good" he says smiling, "this is the only time of the year that we really earn some money". Indeed, after the November 1 holiday, Arnold will go back to being a kalakal boy, his regular job of digging trash to sell to the junk shops.

*Manila North Cemetery is the Philippines oldest and largest cemetery. Formerly known as Sementeryo ng Paang Bundok, the cemetery is located in the boundaries of Caloocan, Quezon City and Manila. Photograph was taken October 31, 2009 at 9 p.m. Manila North Cemetery.

Halloween Spooks

With it being my last post before Halloween, I thought I'd leave you with the best Halloween song ever! It's 'Halloween Spooks' by Lambert, Hendricks and Ross! Do you know any better Halloween songs?

Piano Man

Noah and I went for a ride this morning and he asked if we could listen to some music. I asked him what kind of music he wanted to listen to and he said he wanted to listen to the 'piano music', as he was pointing to the Ray Charles CD I had on the backseat (the CD case had piano keys on it).....

So I explained to him that it was a Ray Charles CD, and that Ray Charles couldn't see anything ever since he lost his eyesight when he was a really young boy and he was really good at playing the piano.

I then asked Noah:

Daddy: You know the piano and Grandma and Papa's house? Remember how hard it is to play that piano? Imagine if you couldn't see the keys?

Noah exasperatedly says: What?!?! I can play that piano!

Then, as he hears the first piano solo, he closes his eyes and plays air piano.

Carotid cavernous fistula

Diagnosis: Carotid cavernous fistula


Discussion

Carotid Cavernous fistula (CCF) is a direct communication between the intracavernous portion of the carotid artery and the venous cavernous sinus. Usually is ipsilateral.
Most often results from significant trauma, penetrating or nonpenetrating.
Spontaneous rupture happens in the elderly.

Spontaneous rupture of CCF also associated with:
- Osteogenesis imperfecta
- Ehlers-Danlos syndrome
- Psuedoxanthoma elastica

Clinical presentation: acute onset pulsating exophthalmos, orbital bruit, dilated conjunctival vessels, and glaucoma. No pain whereas psuedotumor is almost always associated with pain.


Radiology

Unilateral diffuse enlargement of extra ocular muscles.
Proptosis.
Dilation of Superior ophthalmic vein (SOV) and venous structures within the carotid cavernous sinus due to backpressure. Our case was unusual in that the venous engorgement was on the opposite side of the CCF.
Irregularity of SOV may represent thrombus (not seen in this case).
Bowed convexity to the Cavernous sinus usually unilateral (our case demonstrated right cavernous sinus bowing due to the venous engorgement from the opposite carotid-very atypical)
US: reversal of flow in SOV.
Carotid Angio: filling of ophthalmic veins due to decompression of arterial flow with retrograde filling of orbital veins.
Repair: important to determine the extent of contralateral flow in the cavernous sinus without the CCF if carotid must be sacrificed. Glue embolization of the SOV and coiling are the primary treatments.
Diagnosis first by CT orbit findings then proceed to conventional angiogram for diagnosis and treatment.
Treatment: glue embolization and coiling. Approach varies but may go through the SOV from the internal jugular or direct approach by interventional neuroradiologist or neurosurgeon through the SOV as in our case.


Pearls

With carotid cavernous fistula look for enlarged superior opthalmic vein.(SOV) in addition to unilateral rectus enlargement and proptosis.
Need cerebral angiogram to definitively diagnose-may not see enlarged carotid cavernous sinus on CT.
SOV lives between the superior rectus and the optic nerve.
Treatment of CCF is with glue embolization and coiling

One 500 Year Old Fingerprint

Did anybody else hear about this story? A fingerprint may have increased the value of this painting by 8,000 times more than its original selling price. This 13 inch by 9 inch chalk, pen and ink piece of art was sold at Christie's Auction House in New York for $17,000 in 1998, then sold again to an art collector for $19,000 in 2007. The painting was cataloged as 'German school, early 19th century' art.

However, through a process of a process of carbon dating and infrared analysis of the artist's technique, experts have concluded that the piece of art, now being called "La Bella Principessa", was painted by Leonardo da Vinci.

Their most interesting evidence, however, is a fingerprint in the corner of the painting.... Art expert Peter Paul Biro, discovered the print of an index finger on the top left corner of the drawing using state-of-the-art multi-spectral infrared technology, and says the print is "highly comparable" to another fingerprint found on da Vinci's 'St. Jerome' painting in the Vatican.

This fingerprint could change the price of the painting from $19,000 to $150,000,000.

Could you imagine being the person that bought and sold the painting for a $2,000 profit before they found the fingerprint. That's almost as embarrassing as Steve Wynn putting his elbow through a Pablo Picasso painting.

Dreams and Reality

Photograph was taken October 24, 2009 5:00 pm, Philippine National Railway Tracks, (Blumentritt station), Manila. Note: This is an active railway and I am not sure why this boy chose to sleep on it rather than on the bangketas.

Dermoid Ovary-CT

Classical CT image of an ovarian dermoid. Reported by Teleradiology Providers

Chloroma

Findings

Sagittal T1 image of the lumbosacral spine demonstrates decreased marrow signal throughout the lumbosacral vertebral bodies consistent with marrow infiltration secondary to the patient's leukemia.
Axial T2 image through the level of the sacrum demonstrates an isointense lesion originating in the right sacral ala which is invading the S1 and S2 exiting nerve roots. Incidental note is made of a left sacral foraminal Tarlov cyst.
Axial T1 pre and post contrast images demonstrate enhancement of this sacral mass.


Diagnosis: Chloroma

Granulocytic sarcomas are extramedullary masses composed of granulocytic cell precursors, occurring in patients with leukemia or other myeloproliferative disorders. First described by Burns in 1811, they were given the name "chloroma" by King in 1853, due to the green color produced by the high levels of myeloperoxidase in these cells. Recently there has been a shift away from using the term "chloroma", as these cells can have varying amounts of myeloperoxidase and can produce other colors as well. Granulocytic sarcomas most commonly occur in patients with AML, however are still rather rare, occurring in only 2.5-9.1 % of patients with AML. Children are more commonly affected than adults with 60% occuring in patients younger than the age of 15. While granulocytic sarcomas most commonly develop after the diagnosis of AML has been made, they can precede the hematologic leukemia, making their diagnosis more difficult. In these instances, biopsy is necessary to make the diagnosis.

Granulocytic sarcomas often occur in multiple locations at the same time. These tumors have a predilection for the orbits and subcutaneous tissues, but have been reported in the paranasal sinuses, bowel, breast, bone, lungs, peritoneum and pleural space. In the central nervous system, chloromas appear as extra-axial masses which are contiguous to meninges or ependyma. It is believed that intracranial granulocytic sarcomas arise from dural and subarachnoid veins and surrounding adventitia whereas spinal granulocytic sarcomas spread via the perivenous arachnoid space. On unenhanced CT, granulocytic sarcomas appear isodense or hyperdense to brain. On MR, granulocytic sarcomas are hypointense or isointense on T1, isointense or hyperintense on T2 and typically demonstrate homogeneous enhancement. Intracranial chloromas are often associated with mass effect and edema. When granulocytic sarcomas involve the spine, they are typically extradural or intradural extramedullary lesions. Very rarely, these tumors can cause compression of the spinal cord, caude equina or nerve roots. The differential diagnosis for granulocytic sarcomas when they occur in or around the spinal canal includes lymphoma, intraspinal abscess, plasmacytoma, metastatic disease and other primary bone tumors.

There is dispute as to whether patients with granulocytic sarcomas have worse prognoses. Treatment of granulocytic sarcoma is usually with systemic chemotherapy. If the mass is resistant to chemotherapy, localized radiation or surgery may be considered. While treatment is usually successful, recurrence does occur in up to 23% of patients.

Labor Pains

She's finally home. Lucy Marissa was born on October 24, 2009 and was able to come home on her mommy's birthday.



It was an amazing experience to witness labor. My wife was amazing, and now I know, there is no part of labor that I ever want to attempt. Especially while watching her almost rip the bed handles off of the bed during tough contractions....



To add greater emphasis to my conclusion, I watched Dr. Andrew Rochford, host of an Australian health show titles "What's Good For You", attempt to have his stomach muscles manipulated similar to contractions during labor to try and determine whether men or women had higher pain thresholds.... Here's a hint.... Men lose....

Lucy Marissa

Why was there no 7:00 A.M. post this morning?

I was delivering a baby this weekend!

Thanks to Melissa, Miranda, Dr. Barber and all of the other staff at Hoag Hospital for all of your help!

Welcome to the world Lucy Marissa!

Oh yeah, and Happy Birthday to my wife!

Aling Carlita: Yakult Lady

If you're a regular pedestrian in Palengke Blumentritt, Manila, chances are you have already seen Aling Carlita Reyes, 70, peddling around small Yakult milk bottles of Lactobacilli-Shirota strain in her Yakult cart.

But no, Aling Carlita is not your everyday Yakult lady. For one she always come to work in complete Yakult uniform, complete with cap! And she's been selling Yakult for over thirty years now--and because of those three decades of peddling this cultured milk, she had managed to send to college all her five children, who are now all professionals. It's not that she earned a fortune selling Yakult, but as she says, through her "Tiyaga, kayod, at pagtitipid" (Perseverance, hard work, and frugality)

Does Aling Carlita plan to retire soon? "No", she says smiling "I love to work. I have done this work for many years and I would be lonely if I retire. My children all wanted me to retire but I didn't want to stop working. If I stop working, I would probably just sit around in the house and be sickly. Only the sick retires, and I'm very healthy!"



Meanwhile I bought three packs of Yakult from Aling Carlita which instantly made me into her new best friend. As I handed my cash and said goodbye, she said: "Oy may sukli ka pang kwarenta'y tres!!"

I said she can keep the change. We smiled, while I promised to be her regular client from now on. Well, you'll never know when you're helping send a kid go to college by drinking Yakult, do you?



*Disclaimer: this is not a paid ad by Yakult! ;)

My New Favorite Quote

The artwork was done by a woman named Barbara in Virgina Beach. Her art is simple, but it's really cute.... Here are a couple more or her pieces....




You can go to see more of Barbara's art by clicking this link to her flickr page.....

Diffuse Idiopathic Skeletal Hyperosteosis-MRI

DISH diagnostic criteria include the following : Flowing calcifications and ossifications along the anterolateral aspect of at least 4 contiguous vertebral bodies, with or without osteophytes. Preservation of disk height in the involved areas and an absence of excessive disk disease. Absence of bony ankylosis of facet joints and absence of sacroiliac erosion, sclerosis, or bony fusion, although narrowing and sclerosis of facet joints are acceptable.
Lower thoracic spine involvement is typical of DISH, but the lumbar and cervical spine also can be affected. The left side of the spine typically is spared or less involved, which probably is attributable to the pulsating aorta.

Never Underestimate The Power Of A Good Story

R. Kelly could have taken a few hints from this guy....

CNS Lymphoma

Findings

CT: There is a hyper dense mass in the left frontal lobe with compression of the left lateral ventricle and mild midline shift.
MR: There is a uniformly enhancing hypercellular mass in the medial left frontal lobe, extending to the left basal ganglia. Mass surrounds the left lateral ventricle and has associated cerebral edema best demonstrated along its lateral margin.


Differential diagnosis:
- Lymphoma
- Glioblastoma
- Abscess


Diagnosis: CNS Lymphoma


Key points

Malignant primary CNS neoplasm made up of B lymphocytes
1 – 7% of all primary brain tumors
90% of lesions are supratentorial. Commonly frontal and parietal lobes, periventricular with subependymal involvement.
Presents with neurological symptoms, such as headache or seizure.
Typically occurs in the 5th-6th decade, males greater than females.
Immunocompromised individuals are predisposed to all forms of lymphoma, including the CNS form.
Deep gray nuclei commonly affected.
Like GBM, often involves and crosses the corpus callosum.
On CT, hyper dense and relatively uniform in appearance.

MR:
Lesions tend to be homogeneous iso/hypo intense to cortex on unenhanced T1 and T2 weighted images.
May see "blooming artifact" from blood products or calcium on T2*GRE.
Strong homogeneous enhancement.

Differential considerations:
- GBM enhances heterogeneously, unlike lymphoma.
- Abscess usually has a rim that is hypo intense on T2 weighted images, and reveals restricted diffusion.
- Toxoplasmosis also involves the basal ganglia, but subependymal spread is not an associated finding.
- PMNL is a white matter disease, and is typically non-enhancing.

Let's Get Motivated With George W. Bush

Let's pack up the van and get ready to go San Antonio! $19.00 to have George W. Bush motivate your whole office? Who better to motivate us than one of the most despised men in the United States of America?

I do think it's pretty awesome that Bill Clinton makes millions of dollars for speaking at events, and can send your entire office to see George W. Bush and friends for $19.00.

SSPE-MRI

This is a six year old boy with history of measles and neurological complaints. Subacute sclerosing panencephalitis (SSPE) is a progressive, slow virus infection of the brain, caused by the measles virus, attacking children and young adults. In the early period, lesions are in the grey matter and subcortical white matter. They are asymmetrical and had a predilection for the posterior parts of the hemispheres.

The Fun Theory - Update #2

Here's another Volkswagen 'The Fun Theory' commercial! Volkswagen turned a bottle bank (recycling bank) into an arcade-type game. Whenever a light on the bottle bank would flash, the recyclers would need to insert a bottle into the hole with the corresponding flashing light.... 100 points for if a bottle was inserted in the correct hole.... Again, Volkswagen installed the 'bottle bank arcade' to see if adding a little fun to recycling trash would encourage people to recycle more....

Volkswagen says that during one night, their bottle bank was used by nearly one hundred people.... That same night, the bottle bank nearby was used twice....

Hirayama disease

Findings

Figure 1 and Figure 2: Neutral position cervical spine MR images demonstrate mild focal atrophy at C5-C6. Low-lying cerebellar tonsils are also present, although this finding is unrelated to Hirayama disease.
Figure 3: Flexion cervical spine MR image demonstrates increase in the posterior epidural space and a crescent shaped epidural mass at C3-C6.
Figure 4: Extension cervical spine MR demonstrates narrowing of posterior epidural space.


Diagnosis: Hirayama disease

Hirayama disease is a rare condition that primarily affects males aged 15-25 of Southeast Asian decent, although it also can be seen in patients of other heritage. It presents with an insidious onset of asymmetric hand and wrist weakness, muscular atrophy, cold paresis, and exertional fasciculations. The disease progresses for approximately 5 years and then stabilizes. This is a lower motor neuron disease with both acute and chronic denervation identified on EMG in the C7-T1 myotomes. There are no upper motor neuron and generally no objective sensory deficits, although paresthesias can occur.

The specific cause of Hirayma disease is unknown. The prevailing theories are based on the presumption of differential growth of the dura and the osseous spinal canal during puberty. The dura is most strongly anchored near the foramen magnum and the coccyx. Usually, there is enough dural slack to accommodate changes in the length of the spinal canal in cervical flexion. In patients with Hirayama disease, however, it is believed that a relatively short dural sac becomes taut in flexion, pulling the dural sac and spinal cord anterior. This results in cord atrophy, possibly from repeated mechanical trauma or from circulatory insufficiency. Correlative pathological data is limited, but ischemic changes in the anterior horn cells at C7-T1 have been described in autopsy data. Selective involvement of the anterior horn likely results from increased sensitivity of this area compared to white matter to ischemia.

Early in the disease, a cervical collar can be used to mitigate progression. Patients that do not respond to cervical collar treatment and demonstrate compression of the cervical cord against the subjacent vertebral body can be treated with duraplasty and posterior spinal fusion.


Imaging

There are several characteristic radiological features of Hirayma disease. In a neutral position, a cervical spine MR often demonstrates atrophy of the lower cervical spinal cord in the anteroposterior direction, which can be subtle. Some authors have reported that cord atrophy is often asymmetric, predominantly affecting the side corresponding the weakest limb. There can be loss of attachment of the posterior dura to the vertebral lamina or occasionally T2 signal change in the atrophic cord.

On flexion views, the dural sac moves anteriorly, and a crescent shape mass forms posterior to the cord. Interestingly, while the forward movement can be pronounced in the progressive stage of the disease, this finding can be subtle or absent in older, affected patients. Myelography can also demonstrate the forward shift of the cervical spinal cord with flexion, although this examination is technically difficult. The crescent-shaped mass is believed to be due to internal vertebral venous congestion, since it disappears in the neutral position, can have flow voids, and reportedly has demonstrated flow on cinematographic MR. This crescentic mass typically demonstrates high signal on both T1 and T2 weighted images.

Don Conrado Escudero: Custodian of Memory

That he is comfortable in front of my camera's lens is a testament to the fact that he has been a celebrity even among the elite in the Philippines. His annual parties and masquerade balls became the gauge by which one is measured in high society, and being invited into one is a privilege even among the most affluent in the Philippines. "I'm well-known for my big parties" he says proudly, "and I have made all the parties that you can imagine, from Egyptian theme to Americana, and the best part of it is that I have a lot of friends who are game!"

Yet, even at the age of seventy-seven, the gracious Don Ado Escudero, lord of the 400-hectare Hacienda Escudero, has hardly slowed down. Just recently he held a grand ball attended by some of his well-known friends in society including the internationally renowned Filipiniana designer Patis Tesoro. The party was for the opening of his newly completed Plaza del Palmeral Clubhouse, a recent development to his hacienda.



A hands-on haciendero, Don Ado still tours his kingdom everyday, visiting various parts of the hacienda, taking notes on how to improve the facilities, and meeting with tourists who are wowed to learn they are talking with the owner himself. Just recently, he signed a deal with giant Landco Pacific developers to convert more hectares of the hacienda into a tourist resort and park. He plans to make a 1930s theme to his hacienda, the time of his great idol, the flamboyant Manuel L. Quezon, the Commonwealth President.



"I want to create a theme park based on the era of the Philippine Commonwealth" he said proudly. "Right now,we are on the process of beginning that park. It will be unique, it will be grand!"



"Come with me for a ride", Don Ado says to me "I will personally tour you to my hacienda". This was unbelievable. Boarding his golf cart, we toured his estate, with Don Ado as my "chauffer'! I was amazed that he still can drive his cart with great agility. All the while I was thinking, "Good heavens, this man is the lord of this hacienda..and look, he's driving me around for a tour!"



"I'm the only one who can do this" he says beaming as he swiftly turned his cart into a sharp curve on the road.

"I have opened my family property to the public so they too can enjoy a land where there are still a lot of trees around, where you can find rare species of birds that have been extinct somewhere else because of deforestation. I love nature, and I vowed to preserve it within my property. I have made the Hacienda Escudero as a place where you can still feel proud to be a Filipino. When you tour Villa Escudero, you feel you are being transported to the simpler days of Philippine life, where you can ride a boat, a carabao, and inspire yourself to the beauty of the Philippines"



Indeed, the Hacienda Escudero, is the only hacienda that has a themed atmosphere: barrio and nature. When you tour the hacienda, you cannot fail to notice that it was as if you were travelling through the past. The ambiance of history and culture surrounds you, what with the hacienda people in traditional clothes, carabao carts, calesas, and the objects of antiquities that had been assembled by the Escudero family.



The Hacienda Escudero was built by Don Placido Escudero (Don Ado's great grandfather) in the 1870s, establishing the very first coconut industry in San Pablo and Tiaong. During the Second World War, the hacienda got bankrupt and Don Ado's parents had to start rebuilding the hacienda after the war. Although Don Ado's parents--Don Arsenio and Dona Rosario--started the themed atmosphere of the Villa, it was Don Ado who pushed it to the fullest possibility by opening the hacienda to the public. At present, it is the only working plantation/hacienda that the public can visit. The Villa has hundreds of visitors everyday.



Meanwhile, we arrived at another grand mansion located just near the base of Mount Banahaw. The mansion turned out to be the rest house of Don Ado, a house he himself personally built. It is also filled with hundreds of ivory and wooden santos, retablos, relicarios, religious paintings, and other treasures of Filipiniana and orientalia. I thought that it contained more antiques than the Philippine National Museum.



He opened the blinds of the huge window in his bedroom and a breathtaking view of Mount Banahaw presented itself. The mystical mountain, wrapped in thick clouds, make for a fascinating spectacle. Here and there are various species of Philippine trees which Don Ado has staunchly protected against illegal logging.



"This part of the hacienda" he says, "is my home within home. This is my favorite place. So quiet here. I bring a lot of my friends here and just have a nice wonderful afternoon of tea and chat. Isn't it wonderful, to see nature undisturbed?"



I nodded. As a nature lover myself, I thought that this is the kind of place I would want to retire someday, and perhaps if i had the fortune to reach the advance age of Don Ado, I would probably still look young like he does because of lovely surroundings.



Don Ado is a lover of nature, and a lover of history. We talked about a wide variety of subjects: politics, personalities, art, and his collections of antiquities. When he was younger, many people wanted him to become a politician. "But I never wanted to enter the world of politics. It is a dirty game and I don't want to mess with it. All I wanted was to become a farmer" Indeed, proof of his love for farming was his diploma in agriculture that he earned from the prestigious Cornell University in New York.



"Are you related to Senator Chiz Escudero?" I asked.



"Yes, but very distant relations. His family has been into politics for the longest time, but my family was never in any way involved in politics"



Lastly, our conversation turned to his collection of santos. I mentioned that I have never seen a collection of santos as many as his.



"They protect me" he says "and they bring me good blessings in life". As a devoted Catholic myself, I felt that it was true if one considers Don Ado's length of life, fortune, and happiness.



Meanwhile it was already getting late and my companions from the Vibal Foundation have already finished their task of photographing the Escudero Museum. I thanked Don Ado for his kindness and warm hospitality, and that I would forever treasure this wonderful experience of touring the Hacienda Escudero and its fantastic collections of antiquities.



"Wait", Do Ado said with a smile, "I want to give you this." It was a book about him published by his friends. He signed the book with a dedication and gave it to me. It was almost unbelievable. I promised him that I would return to the Hacienda and give him something in return.



The likes of Don Ado may be very few in this world: rich in wealth and heart, noble, gentleman, but very very down to earth.

Don Ado driving his cart

We passed by this carabao cart on the way to tour guests around the hacienda











One of the hundreds of ivory santos inside the rest house of Don Ado is this magnificent Nuestra Senora del Rosario (Our Lady of the Most Holy Rosary)





Inside his moated library containing some very rare books





Don Ado. Behind him is the original Louie XVI tapestry from Versailles Palace. He bought the tapestry at Sotheby's. The French government wanted to buy back the tapestry but Don Ado said his house was not an antique shop.





Don Ado signing the book he gave to me as souvenir