Jyotindu Debnath

Computed tomographic demonstration of unusual ossification of the falx cerebri: a case report

Bony metaplasia of the falx cerebri is rare in human being. We describe a case of extensive ossification involving anterior half of the falx cerebri in a 47-year-old male. This was detected incidentally during computed tomographic examination of the brain for an unrelated cause. The pattern of ossification as demonstrated in the computed tomography scan comprised of dense cortical bone peripherally with medullary bone in the centre resembling the skull vault.

Writing and publishing a scientific paper: Facts, Myths and Realities

Scientific communication and writing forms an integral element of constantly developing and evolving health sciences. Scientific research and writing forms a foundation on which stands the future of mankind and the environment. Being a health care professional, it is our collective responsibility to ensure constant updating of the existing knowledge and imparting any new concept/idea with rest of the medical fraternity. On a day to day basis, many of us tend to become quite satisfied after having delivered the right quality of health care to our dependant clientele. Yes, rightly so. But, how many of us have wondered as to what we have really done for the continuance and enhancement of the existing knowledge which we have acquired as a result of a lot of hard work by our predecessors? It is, indeed, time to introspect on this pertinent and important issue. Many of us, at some point of time, must have felt the need and wish to share our unique experiences with our colleagues in the medical fraternity. It is also true that possibly many such felt needs were never translated into effective scientific communications for various reasons. Of late, there has been a constant palpable pressure on the health care professionals to write and publish scientific papers as a part of mandatory requirement of various universities and medical councils. It may appear like a big challenge to those who are not familiar with scientific publications. On the contrary, we are quite certain that, all of us have the potential to write and publish our research work in various scientific journals. This editorial is aimed at addressing certain important issues concerning scientific writing and publications. We shall also endeavor to unfold and eliminate some of the unfounded myths and fears which may have deterred us from successfully writing and publishing our scientific work.

Clinical mimics of acute appendicitis: Is there any role of imaging?

Acute appendicitis (AA) is a common surgical emergency. Accurate and timely diagnosis of AA is essential for successful outcome. Imaging plays an important role in the diagnosis, exclusion of AA as well as diagnosing alternative clinical conditions which can closely simulate AA. A correct alterative diagnosis may obviate the need of unnecessary appendectomy or may even change the treatment regime altogether. This pictorial essay illustrates various clinical conditions which mimicked AA clinically during our day to day practice.

Comparative analysis of changes in MR imaging of pre and post intrauterine progesterone implants in adenomyosis cases

BACKGROUND Magnetic Resonance Imaging (MRI) plays an important role in the evaluation and management of adenomyosis. In this study, we first diagnosed the adenomyosis on MRI and then we analyzed the MRI changes in the uterus in pre and post intrauterine progesterone implants cases. METHOD All the patients with clinical diagnosis of menorrhagia or dysmenorrhea were screened by Ultrasonography (USG) of the pelvis. Patients with heterogeneous echo texture of the uterus were then evaluated by the MRI of the pelvis. All patients with MRI findings suggestive of adenomyosis formed the study group. RESULT On MRI study 60 patients were diagnosed as adenomyosis, 68.33% had diffuse adenomyosis and 31.66% had focal adenomyosis. 83% of diagnosed adenomyosis cases had high intensity signal foci which were seen in 75% cases of diffuse adenomyosis and 100% cases of focal adenomyosis. 50 diagnosed adenomyosis cases were then reviewed after 03 months, 06 months and 12 months to see for any change in the MRI findings in the post intrauterine implant cases. On follow up MRI after post progesterone intrauterine implant, 50% of the cases showed reduction in the high intensity signals, 10% of the cases showed mild reduction in the junctional zone thickness with no significant change in the uterine size. CONCLUSIONS It is inferred that MR imaging is not only helpful in diagnosing but also helpful in monitoring the effects of hormonal therapy in adenomyosis.

Is it acalculous cholecystitis or reactive/viral pericholecystits in acute hepatitis?

titled “Acute acalculous cholecystitis in a teenager with hepatitis A virus infection: a case report” published in the February 2009 issue of the Brazilian Journal of Infectious Diseases. The authors describe a case of acalculous chole-cystitis (AC) in a 16-year-old male during an episode of hepatitis A virus infection. Diag-nosis of AC had been made on the basis of clinical symptoms and signs supported with sonographic scan evidence. The authors have presented four ultrasonography (USG) scan images (Figures 1-4) supporting a diagnosis of AC. It has been mentioned that the gall bladder wall was thickened and surrounded by echo-genic content. After analyzing the USG images carefully, we strongly feel that the given images may not support a diagnosis of AC. The size of the gall bladder (GB) as shown in Figure 1 ap-pears rather small. Besides, there has been no mention about any abnormality of the GB con-tents. Mere presence of gall bladder wall thick-ening and pericholecystic fl uid is not enough for a diagnosis of AC as such fi ndings are not uncommon in acute hepatitis without AC.

Temporal evolution of emphysematous pyelonephritis in a renal allograft: imaging findings

Emphysematous pyelonephritis (EPN) is a rare, lifethreatening infection of the kidney characterized by the presence of gas within the renal parenchyma, renal collecting system, and perinephric tissue. It is usually seen in elderly diabetic patients. Although rare, EPN in a renal transplant allograft is a serious and potentially fatal complication. Management of EPN in a graft kidney has been a subject of controversy. Traditionally, graft nephrectomy has been the standard treatment of choice in such cases. Recently, there have been reports of successful nonsurgical management of EPN [1–4]. We describe the imaging findings of temporal evolution of EPN in a renal allograft recipient who was managed successfully with medical treatment alone.

Imaging in acute appendicitis: What, when, and why?

Acute appendicitis (AA) is the commonest cause of pain abdomen requiring surgical intervention. Diagnosis as well as management of acute appendicitis is mired in controversies and contradictions even today. Clinicians often face the dilemma of balancing negative appendectomy rate and perforation rate if the diagnosis is based on clinical scoring alone. Laboratory results are often non-specific. Imaging has an important role not only in diagnosing appendicitis and its complication but also suggesting alternate diagnosis in appropriate cases. However, there is no universally accepted diagnostic imaging algorithm for appendicitis. Imaging of acute appendicitis needs to be streamlined keeping pros and cons of the available investigative modalities. Radiography has practically no role today in the diagnosis and management of acute appendicitis. Ultrasonography (USG) should be the first line imaging modality for all ages, particularly for children and non-obese young adults including women of reproductive age group. If USG findings are unequivocal and correlate with clinical assessment, no further imaging is needed. In case of equivocal USG findings or clinico-radiological dissociation, follow-up/further imaging (computed tomography (CT) scan/magnetic resonance imaging (MRI)) is recommended. In pediatric and pregnant patients with inconclusive initial USG, MRI is the next option. Routine use of CT scan for diagnosis of AA needs to be discouraged. Our proposed version of a practical imaging algorithm, with USG first and always has been incorporated in the article.

Can ultrasonography reduce the need for CT scan in diagnosing acute appendicitis

We readwith interest the article titled “Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template”written by Nielsen et al and published in the January 2015 issue of the Journal of Pediatric Surgery [1]. We find the article very relevant, highlighting the utility of adherence to standardized ultrasonography template for diagnosing acute appendicitis (AA). The article comes at a time when CT scan usage has increased exponentially for the diagnosis of AA disregarding its potential harmful effects. Having gone through the article we have the following comments: We fully agree with the authors that a meticulous ultrasonography (USG) by an expert keeping inmind of the primary aswell as secondary signs of AA would obviate the need for CT scan in a sizeable number of patients. In fact, we firmly believe that, this is true not only for pediatric age groups but across all age groups. In children, young females and nonobese young males, we do not see any reason to ask for CT scan as the first modality of imaging for diagnosing AA ignoring the important role of USG.With due respect toUSG technicians,wewould like tomention here that, USG for suspected AA is best done by trained radiologists as it happens in most parts of India. Having practicing USG for more than 15 years, we find that it is extremely important for the concerned radiologist to interact with the patient of suspected AA and preferably carry out a quick clinical assessment before starting the USG. Many a times, self localization of maximal point of pain/tenderness by the patient can serve as a useful guide to look for the inflamed appendix. When secondary signs are present and the appendix is not visualized, one must make all efforts to look for the same. It is our observation that, if there is associated tachycardia, one should make deliberate attempt to look for the inflamed appendix or any other inflammatory pathology. In young females, endovaginal USG (as indicated) can often reveal alternative causes which can explain the clinical condition very well. CT scan, can very well, be considered as a problem solving tool in cases where USG results are not satisfactory. There are specific situations, where a CT scan would score over USG e.g. an obese patient, retrocecal appendix etc. We strongly feel that there is an urgent need to develop a universal imaging algorithm as to which patients should undergo what imaging test and when, with strict adherence to standard guidelines. It is interesting to see thatmany studies advocating increasing accuracy of CT scan for the diagnosis of AA as compared to USG have recorded a significant number of CT scans having been done in cases which did not have a final diagnosis of AA. We are certain that there is no need to rush for a CT scan study for every case of suspected AA for the fear of missing the diagnosis irrespective of the age and sex. A dedicated appendiceal Journal of Pediatric Surgery 50 (2015) 1076–1078

Alvarado score: is it time to develop a clinical-pathological-radiological scoring system for diagnosing acute appendicitis?

We readwith interest the article titled “Alvarado score: can it reduce unnecessary computed tomographic (CT) scans for evaluation of acute appendicitis (AA)?”written by Apisarnthanarak et al and published online ahead of print in the Am J Emerg Med 2014 [1]. We find the article interesting on several accounts as detailed below. The authors have made several categorical statements in the introduction section and have given references to support them. Firstly, although explaining the role of CT scan, the authors state that a true alternative diagnosis may be evident if an appendix is found to be normal on CT scan unlike ultrasonography (USG) [2,3]. Interestingly, both the studies referred by the authors are centered on CT scan and do not dealwithUSG at all.We are afraid, this particular statementmay convey erroneous message to the readers that USG has practically no role in providing alternative diagnosis in clinically suspected cases of AA. Well, there is enough literature available to support the fact that USG has an important role in not only diagnosing AA but also excluding a diagnosis of AA. In many such cases, USG can provide clinically useful and accurate alterative diagnoses as well. It is important to understand at this point that both USG and CT scan have its share of pearls and pitfalls in the diagnosis and management of a case of AA. Secondly, the authors also state that CT scans performvery high for thediagnosis of AA regardless of the technique and CT protocol used. The authors refer to a study in support of their statement [4]. Interestingly, the study under reference does not compare various CT protocols except a remark in the result section under the subheading of CT technique. Can we really extrapolate such statements in amanner it has been done in the present article? Having worked in various CT scan for more than 7 years, we firmly believe that success of diagnosing of AA on CT scan depends a lot on the CT protocol used, various reconstruction parameters, use of contrast media (oral, rectal, and intravenous), patient characteristics (age, presence/absence of sufficient fat around the appendix, anatomic disposition of the appendix, stage of the disease process, presence or absence of complications, etc), and, last but not the least, experience of the radiologist interpreting the CT scan images. Computed tomographic scan usage has seen exponential rise for the diagnosis of AA, in the name of increased accuracy with total disregard for its harmful effects.Well, nodoubt that usage of CT scan has increased the accuracy of diagnosis of AA. Here, 2 issues need attention: (1) How many cases diagnosed as AA based on CT scan could also have possibly been diagnosed on USG alonewithout the need for a CT scan hadwe selected the appropriate imaging algorithm? (2) CT scan is often considered accurate in providing alternative diagnoses in those cases where appendix is found to be normal. The question that needs to be answered here is that, couldmany such alternative diagnoses possibly beenmade

Congenital giant hydronephrosis: A rare cause for upper abdominal mass in the newborn

We report a rare case of antenatally detected unilateral pelvi–ureteric junction obstruction leading to congenital giant hydronephrosis presenting as upper abdominal mass at birth.