Friday, May 22, 2015

Smell of victory

Strange are the ways of the world.
People who lose don't know how to win. Losing instead of stimulating them to work harder, acts as a vicious circle and they get more and more negative and their losing streak continues.
On the other what is the secret of winners, they work when they smell victory. A tiny sentinel win, which otherwise would seem useless to others, stimulates them to do extra-ordinary effort. They can subconsciously feel the possibility of winning.
You don't put extra-ordinary effort when you lose although, stories make you think that is the case. In real life, you need to get the sense of impending win.
That's the smell of victory. That's the most potent stimulant.

Thursday, May 21, 2015

Castleman's Disease- Clinicoradiological Series

Castleman Disease, described as a flashcard with clinicoradiolgical correlation. 

Pneumococcal pneumonia-DAMS clinicoradiological Series

Solitary Pulmonary Nodule-CT

Incidentally detected lung nodule on CXR and followed up by CT, which shows lobulated outline lung nodule and mediastinal lymphnodes were also noted and biopsy was suggested for neoplastic etiology.

Teaching Points
1.      A lung nodule has been defined by the Nomenclature Committee of the Fleischner Society as a rounded opacity, well or poorly defined on a conventional radiograph, measuring up to 3 cm in diameter.
2.      On computed tomography (CT) scan, a nodule appears as a rounded or irregular opacity, well or poorly defined, measuring up to 3 cm in diameter.  Opacity less than 3 mm is defined as a micronodule.
3.      Mimics of pulmonary nodules include pseudonodules, which represent a rib fracture, a skin lesion, a device outside the patient, anatomic variants, or composite areas of increased opacity.
4.      The initial step after discovery of a SPN is to determine its cause and characterize it as definitely benign, equivocal, or definitely malignant on radiologic features.
5.      Benign nodules include infectious granulomas and hamartomas, whereas common malignant causes include primary lung cancer, carcinoid tumors, and lung metastases.
6.      Radiologic features, such as size, morphology, and rate of growth, help to determine the likelihood of malignancy in a majority of patients. 

Placenta Increta: MRI

29 yr old multiparous lady with history of LSCS  suggests low lying placenta on USG at 20 weeks gestation. MRI clearly delineates  irregular large placenta with villi invading  myometrium with subtle bleed on T1 and FFE with  villi  not reaching to serosa and beyond suggesting   invasive placenta of increta variety

Teaching points by Dr MGK Murthy and Mr Samuel MRI technician

1.Low lying placenta is placental edge that comes within 2 cm of cervix on USG (better measured on TVS). Invasive placenta are (a) Accreta , abnormally adherent  placental villi attached directly in to myometrium, but not invade it   (b) Increta is  villi invade myometrium when they reach serosal surface , percreta is suggested

2. Placenta previa (normally 1 in 300 patients )  is higher with advancing age , history of Caesarean, with maternal  mortality (3 per 1000 cases)and abruption placenta possible

3. Invasive placental aetiologies  include  impairment of  the  apparent  relative  cranial migration  (with differential growth rates of uterus)/ scarred lower uterine  segment not growing adequately in 3rd trimester, smoking (hypoxic mechanism),  thin, incompletely developed   or absent decidua basalis (including protective nitabuchs layer), multiparous lady (because of thicker palcenate), any circumstance leading to damaged uterus or myometrium or decidua etc

4. Overdistended bladder may produce false  previa on USG(routine use of post void scan in high risk useful). TVS is specific to  low lying placenta  in view of proximity. Transperineal USG may help

5. USG shows  absence of normal retroplacental clear space, placental tissue contiguous with myometrium, prominent venous lakes, vascularity (abnormal basal plate) , absent hypoechoic zone suggesting decidua defect. Doppler shows continuum of lacunar flow from placenta through myometrium

6.Treatment of  invasive variety is  obviously  challenging   including bleeding, thrombolysis, thromboprophylaxis after delivery etc  and is usually individualized

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